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PUBLIC  HEALTH  ADMINISTRATION  AND 

m 

THE  NATURAL  HISTORY  OF  DISEASE 
IN  BALTIMORE,  MARYLAND 

1797-1920 


BY 

William  Travis  Howard,  Jr.,  M.  D. 


'HF  IIRHftRY  Of  ■»  l 
DEC  1  2  1924 

UNIVERSITY  OF  ILLINOIS 


Published  by  the  Carnegie  Institution  of  Washington 
Washington,  September,  1924 


CARNEGIE  INSTITUTION  OF  WASHINGTON 

Publication  No.  351 


jSorfc  Q^afftmore  (press 

BALTIMORE,  MD.,  0.  S.  A. 


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PREFACE. 

In  this  work  the  author  has  attempted  to  portray  the  development  of  the 
laws  and  practices  of  public-health  administration  in  Baltimore,  to  trace  the 
ideas  underlying  their  origin  and  gradual  evolution,  to  inquire  into  the  natural 
history  of  those  diseases  which  may  be  followed  in  the  records  of  the  Health 
Department,  and,  finally,  to  correlate  as  closely  as  possible  all  the  ascertainable 
factors  that  may  have  influenced  their  courses.  For  the  latter  purpose,  it  has 
been  necessary  to  present  in  some  detail  the  essential  facts  concerning  the 
location,  origin,  and  growth  of  the  city,  the  medical  profession,  the  hospitals 
and  other  public  agencies,  the  dwellings,  and  the  growth  and  racial  composition 
of  the  population. 

The  foundations  of  this  study  were  laid  for  very  practical  reasons,  during 
the  author’s  service  as  assistant  commissioner  of  health  for  the  four  years 
ending  in  the  autumn  of  1919.  The  first  two  years  of  the  period  were  crowded 
with  the  details  of  administration,  which  necessitated  intimate  acquaintance 
with  the  history,  the  personnel,  and  the  activities  of  each  and  every  bureau  and 
division  of  the  health  department.  During  the  last  two  years,  through  the 
broadmindedness  and  interest  of  Mayor  James  H.  Preston,  who  readily  appre¬ 
ciated  the  importance  of  accurate  study,  by  epidemiological  and  statistical 
methods,  of  the  natural  history  of  the  diseases  the  city  was  undertaking  to 
combat,  provision  was  made  for  relief  from  administrative  detail. 

Beginning  with  typhoid  fever  and  tuberculosis,  systematic  studies  were 
made  of  the  common  communicable  diseases,  in  turn,  by  mortality  since  1827 
and  by  morbidity  since  1898.  Studies  of  poliomyelitis,  tuberculosis,  typhoid 
fever,  influenza,  infant  mortality,  accidents,  and  of  the  influence  of  race  stock 
upon  mortality  of  various  diseases  were  published  in  the  annual  reports  for 
1916,  1917,  and  1918. 

These  studies  were  directed  primarily  to  three  main  objectives,  namely,  the 
elucidation  of  the  actual  problems  of  disease  control,  critical  appraisal  of  the 
efficacy  of  the  methods  in  use,  and  modification  and  further  development  of 
methods  in  the  light  of  knowledge  that  might  be  gained.  Investigation  soon 
disclosed  truths  which  lead  to  conclusions  at  variance  with  many  accepted 
doctrines  and  practices  of  public-health  administration.  It  soon  became  evi¬ 
dent  that  in  many  respects  the  game  is  far  more  cunning  than  its  would-be 
trappers,  and  that  the  problems  of  control  and  extinction  of  many  of  the  com¬ 
municable  diseases  are  concerned  with  great  and  fundamental  problems  of 
general  biology  far  transcending  present  knowledge  and  the  solution  of  which 
lies  beyond  the  scope  of  present-day  health  officials  and  sanitarians  in  general. 
Some  of  the  advice  offered  as  the  result  of  these  studies  was  accepted,  but 
much  was  rejected  as  too  unorthodox. 

It  was  Professor  Raymond  Pearl  who  first  appreciated  the  real  value  of  the 
data  thus  collected  and  who  suggested  that  the  scope  of  the  investigation  be 
expanded  and  the  results  published  in  book  form.  To  this  end,  among  others, 
his  invitation  in  the  autumn  of  1919  to  join  his  staff  was  heartily  welcomed. 
In  November  of  that  year  the  statistical  and  historical  data,  with  many  of  the 

m 


562420 


IV 


PREFACE 


personal  notes  of  the  author  on  local  epidemics  of  recent  years,  were  destroyed 
by  fire.  The  work  was  begun  anew  and  on  a  wider  scale. 

Some  explanation  of  the  groupings  of  certain  communicable  diseases  here 
adopted  is  necessary.  The  division  of  these  affections  into  nuisance-borne  and 
contactive  was  dictated  by  historical  and  administrative  as  well  as  by  analogical 
reasons.  The  author  is  not  unaware  of  the  facts  that  many  of  the  diseases  classi¬ 
fied  in  this  work  as  nuisance-borne — the  acute  intestinal  diseases,  for  example — 
may  be  and  often  are  spread  by  contact,  and  some  of  those  listed  among  the 
contactive  affections  are  capable  of  being  spread  by  other  means.  In  spite  of  its 
obvious  drawbacks,  this  old  distinction  still  possesses  many  notable  advantages. 

Many  and  perhaps  indeed  most  of  the  observations  recorded  and  the  con¬ 
clusions  reached  in  this  work  are  not  new  in  the  sense  that  they  have  not  been 
made  before.  Whatever  of  value  this  work  may  possess  in  these  respects  lies  in 
the  variety,  extent,  and  comparative  accuracy  of  the  original  data  in  regard  to 
the  particular  diseases  and  to  total  mortality,  the  critical  care  with  which  they 
have  been  sifted,  and  their  correlation  with  public-health  activities  over  so  long 
a  period  of  time.  It  is  hoped  that,  quite  independent  of  the  use  made  of  these 
statistical  data  in  this  work,  inquiring  students  of  statistics,  of  medicine,  and  of 
public  health  may  find  in  them  material  convenient  for  their  several  purposes. 
The  author  is  conscious  that  much  of  this  material  deserves  wider  and  more 
refined  treatment  by  statistical  methods  than  is  here  attempted,  and  hopes 
that  this  store  of  biological  data  thus  made  generally  available  may  prove  useful 
to  others  more  capable  in  the  practice  of  such  methods. 

The  arithmetical  work  has  been  done  with  the  greatest  care  and  checked 
several  times,  but,  in  calculations  on  such  a  large  scale,  it  is  not  improbable  that 
occasional  mistakes  have  crept  in.  However,  all  the  factors  necessary  for  their 
proof  are  given  in  appropriate  tables.  In  order  to  keep  this  work  within  reason¬ 
able  bounds,  the  temptation  to  make  comparisons  with  other  places  has  been 
studiously  restrained. 

While  gratefully  acknowledging  his  deep  indebtedness  to  his  associates  for 
advice  and  criticism,  without  which  this  work  would  not  have  been  possible,  the 
author  assumes  full  responsibility  for  the  opinions  expressed  and  for  the  con¬ 
clusions  reached. 

To  his  colleague  and  dear  friend,  Professor  Raymond  Pearl,  for  his  generous 
counsel,  guidance,  and  criticism  and  for  the  opportunity  to  work  under  his 
stimulating  aegis,  the  heartiest  thanks  are  tendered. 

For  information  and  advice  the  author  is  under  deep  obligations  to  many 
associates  in  the  department  of  health  and  to  his  colleagues  in  the  department 
of  biometry  and  vital  statistics,  and  among  the  latter  Drs.  Lowell  J.  Reed  and 
John  Rice  Minor  are  especially  to  be  mentioned.  Last  and  by  no  means  least, 
the  author  acknowledges  with  gratitude  his  debt  to  his  secretary,  Miss  Audrey 
W.  Davis,  for  faithful  and  painstaking  help  in  securing  and  tabulating  data 
and  in  calculating  rates,  and  above  all  for  indispensable  assistance  in  the  ar¬ 
rangement  and  composition  of  this  work. 

William  Travis  Howard,  Jr. 

Department  of  Biometry  and  Vital  Statistics, 

School  of  Hygiene  and  Public  Health,  The 
Johns  Hopkins  University. 

Baltimore,  Maryland,  March  7,  1923. 


CONTENTS. 

Part  I.  Certain  Physical  and  Sociological  Data  Concerning  Baltimore. 

page 


Chapter  1 .  1 

Location  and  topography;  Settlement  and  growth  in  area;  Factors  deter¬ 
mining  expansion  in  commerce,  industry,  and  wealth ;  Forms  of 
government;  Meteorology.  (Maps  1  and  2;  Tables  1  to  3.) 

Chapter  II .  11 

Physicians;  Medical  education;  Hospitals  and  dispensaries;  Charities; 

Schools;  Dwellings. 


Part  II.  Historical  Development  of  the  Health  Department  and  of  Health  Laws 
and  Regulations  in  Baltimore  and  the  State  of  Maryland. 


Chapter  III.  Ideas  Underlying  the  Public  Health  Laws  of  Baltimore .  33 

Chapter  IV.  Evolution  of  the  Public  Health  Laws .  47 

1.  Baltimore  Town 


2.  Baltimore  City:  The  two  fundamental  ordinances  of  1797,  Ordinance 

No.  11  and  subsequent  amendments  and  additions  dealing  with  the 
organization  of  the  health  department  and  the  duties  and  powers  of 
health  officials,  the  reporting  and  isolation  of  cases  of  communicable 
diseases  within  the  city,  quarantine  of  the  port;  Hospitals  controlled 
by  the  city  and  the  registration  of  births  and  deaths,  and  of  physicians, 
midwives,  and  undertakers;  Ordinance  No.  15  and  subsequent  amend¬ 
ments  and  additions  dealing  with  nuisances,  namely:  General  sanita¬ 
tion  on  public  domains — street  cleaning,  garbage,  night-soil  collection 
and  disposal,  food  control — and  sanitation  on  private  domains — privies, 
cesspools,  night-soil,  standing  water,  and  decaying  materials,  cellars, 
manufactories  injurious  to  health,  garbage,  habitations,  plumbing, 
foods. 

3.  State  of  Maryland:  Contagious  and  infectious  diseases;  Vaccination; 

Medical  practice;  Registration  and  licensing  of  midwives;  Pharma¬ 
cists;  Nurses,  plumbers,  undertakers,  and  barbers;  Registration  of 
births  and  deaths;  Lunacy  commission;  Child  and  other  labor  laws; 

General  nuisances;  Foods;  Building  inspection. 

Part  III.  Public  Health  Administration  of  Baltimore. 

Chapter  V.  Public  Health  Measures  without  the  City .  83 

Development  of  quarantine  laws  and  practices;  Lazaretto  and  quarantine 
hospitals  of  the  Port  of  Baltimore;  Effectiveness  of  maritime  quaran¬ 
tine. 

Chapter  VI.  Public  Health  Administration  within  the  City .  97 

I.  Introduction:  Developments  and  accomplishments  of  public-health 

practice  in  the  nineteenth  century  based  upon  ideas  and  methods  long 
existent  and  determined  very  largely  by  the  more  general  diffusion  of 
knowledge  and  wealth  among  peoples  of  intellectual  and  personal  free¬ 
dom;  Influence  of  modern  micro-parasitology;  Reasons  for  vigorous 
attacks  on  nuisances  rather  than  on  contactive  diseases. 

II.  Measures  of  nuisance  prevention  and  abatement  directed  against 
nuisance-borne  diseases:  Definition  of  nuisance;  Prevention  and 
abatement  of  nuisances  on  public  property — Dredging  and  filling; 

Grading  and  paving;  Street  cleaning  and  garbage  removal;  Sewerage; 

Water;  Food;  Prevention  and  abatement  of  nuisances  on  private 
property — Standing  water;  Organic  material;  Manufactories,  habita¬ 
tions. 

III.  Measures  of  restriction  directed  against  contagious  diseases:  Isolation, 
inoculation,  and  disinfection.  (Tables  4  to  6.) 


v 


VI 


CONTENTS 


PAGE 

Chapter  VII.  The  Administrative  Officers  and  Subdivisions  of  the  Health 

Department  . 1 .  157 

Commissioners  of  health;  Vaccine  physicians  or  health  wardens;  Division 
of  statistics;  Plumbing  division;  Laboratories;  Inspection  of  school 
children;  Nursing  bureau;  Bureau  of  communicable  diseases; 

Bureau  of  infant  welfare;  Miscellaneous  services.  (Tables  7  and  S.) 


Part  IV.  Population  and  Statistical  Data. 

Chapter  VIII .  173 

1.  Population:  Rate  of  growth;  Racial  composition;  Distribution  by 

numbers,  sex,  and  race.  (Tables  9  to  13,  Graph  1.) 

2.  Natality:  Living  births;  Still-births.  (Tables  10  to  15  and  124,  126,  132.) 

Chapter  IX.  Statistical  Material .  191 

Character;  Sources;  Uses;  Methods. 


Part  V.  Febrile  Diseases. 

Chapter  X.  Nuisance  Diseases  .  199 

1.  Insect-borne  diseases:  Malaria;  Yellow  fever;  Typhus  fever.  (Tables 

16  to  18,  Graphs  2  to  4.) 

2.  Acute  inflammatory  affections  of  the  intestinal  tract  characterized  by 

frequent  loose  stools  of  abnormal  composition;  Diarrhoea;  Dysentery; 

Asiatic  cholera;  Typhoid  fever.  (Tables  19  to  33,  Graphs  5  to  10.) 

Chapter  XI.  Typically  Contactive  Diseases. .  275 

1.  Acute  exanthematous  diseases:  Small-pox;  Cow-pox;  Chicken-pox; 

Scarlet  fever;  Measles;  Influenza.  (Tables  34  to  59,  Graphs  11  to  16.) 

2.  Acute  inflammatory  affections  of  the  respiratory  tract :  Whooping-cough ; 

Diphtheria;  Pneumonia.  (Tables  60  to  77,  Graphs  17  to  20.) 

3.  Tuberculosis.  (Tables  78  to  90,  Graphs  21  to  26.) 

Chapter  XII.  Other  Acute  Infectious  Diseases,  some  apparently  Contactive...  418 
Acute  meningitis;  Poliomyelitis;  Tetanus  and  erysipelas;  Appendicitis. 

(Tables  91  to  100  and  34,  128,  131.) 


Part  VI.  Various  Chronic  Organic  Diseases. 

Chapter  XIII.  Tumors.  (Tables  101  to  109,  Graphs  27  to  29.) .  435 

Chapter  XIV.  Diseases  of  the  Cardio-Vascular-Renal  System.  (Tables  101,  110 

to  116,  Graphs  27  to  29.) .  454 

Chapter  XV.  Diseases  of  the  Central  Nervous  System  and  Liver .  469 

Diabetes;  Alcoholism.  (Tables  117  to  119.) 

Part  VII.  Miscellaneous  Causes  of  Death. 

Chapter  XVI.  Violence.  (Tables  120  to  123,  Graphs  30  to  32.) .  *  479 

Chapter  XVII.  Child-birth.  (Tables  124  to  127,  Graphs  33  to  34.) .  487 

Chapter  XVIII.  Ill-defined  Causes .  498 

Diseases  of  early  infancy;  Arthritis;  Hernia  and  intestinal  obstruction. 

(Tables  128  to  131.) 


Part  VIII.  General  Conclusions. 

Chapter  XIX.  Deaths  from  All  Causes.  (Tables  132  to  139,  Graphs  35  to  41.) . .  507 

Chapter  XX.  Summary  and  Conclusions .  531 

Febrile  diseases;  Affections  peculiar  to  child-birth  and  to  early  infancy; 
Violence;  Chronic  organic  diseases.  (Tables  140  and  141.) 

Bibliography  .  563 


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This  plat  shows  the  City  as  it  appeared  about  the  time  of  its  incorporation. 


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PART  I.— PHYSICAL  AND  SOCIOLOGICAL  DATA 

CONCERNING  BALTIMORE. 


Chapter  I. 

Location  and  topography;  Settlement  and  growth  in  area;  Factors  de¬ 
termining  expansion  in  commerce,  industry,  and  wealth;  Forms  of  govern¬ 
ment;  Meteorology.  (Maps  1  and  2;  Tables  1  to  3.)  (1  to  8.)1 

LOCATION  AND  TOPOGRAPHY. 

Baltimore,  the  chief  city  of  the  State  of  Maryland  and  of  the  southern  At¬ 
lantic  seaboard,  is  situated  in  latitude  39°  17'  N.  and  longitude  76°  37'  W.,  on 
the  Patapsco  River  and  the  Middle  and  Northwest  Branches,  at  the  point  where 
these  join  to  form  a  broad  and  deep  estuary  leading  directly  to  the  Chesapeake 
Bay  some  12  miles  distant.  At  the  head  of  tidewater,  172  miles  from  the  At¬ 
lantic  Ocean,  from  which  it  is  approached  over  a  great  and  easily  navigable 
inland  sea,  with  safe  and  ample  harbor  and  convenient  piers  and  with  good 
communications  with  a  territory  rich  in  natural  and  developed  resources,  it 
occupies  an  important  strategic  position  as  a  port  of  entry,  exit,  and  distribu¬ 
tion  for  domestic  and  foreign  trade.  Its  past,  present,  and  future  are  intimately 
bound  up  with  these  circumstances. 

A  second  attribute  of  deep  significance  dependent  upon  physical  geographical 
characters  is  the  city's  situation  on  the  fall  line,  at  the  junction  of  the  alluvial 
and  Piedmont  soils,  or  where  the  water-laid  coastal  and  the  granitic  forma¬ 
tions  meet.  Indeed,  the  city  straddles  these,  its  lower  portion,  or  water  front, 
being  on  the  former,  and  its  larger  and  higher  sections  resting  on  the  latter. 
Away  from  the  water  front  the  soil  consists  of  clay  and  sand  hills  covered  in 
many  places  with  a  thick  coat  of  gravel.  This  series  of  hills,  rising  from  10  to 
nearly  200  feet  above  tide,  has  in  the  main  a  northeast  and  southwest  direction. 
Between  them  course  in  a  general  northerly  and  southerly  direction  five 
streams.  Two,  Harford  Run  and  Jones  Falls,  running  through  deep  and  some¬ 
what  irregular  valleys  and  carrying  considerable  volumes  of  water,  empty  into 
the  Northwestern  Branch  or  Basin;  the  other  three,  Rutter's  Run  and 
Schroeder's  Run,  both  comparatively  small,  and  the  larger  Gwynn's  Falls  dis¬ 
charge  into  the  Middle  Branch. 

Gwynn's  Falls  is  near  the  extreme  western  boundary  and  Jones  Falls  bisects 
the  city  into  two  nearly  equal  parts,  the  eastern  and  the  western  sides.  In 
earlier  days,  before  the  city  was  built  up,  a  number  of  smaller  brooks  fed  from 
springs,  and  coursing  through  narrow  valleys  between  the  hills,  discharged, 
either  directly  or  indirectly  by  means  of  the  above-mentioned  streams,  into  the 
basin  or  into  the  Middle  Branch.  These  and  other  topographical  features  yet 
to  be  described  may  be  followed  on  maps  1  and  2. 

At  different  periods  in  the  city's  history  all  these  streams,  with  the  exception 
of  Gwynn's  Falls,  have  been  covered  over.  Originally  the  valley  of  Jones  Falls, 


1  Figures  in  parenthesis  refer  to  bibliography  at  end  of  this  volume. 


1 


2 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


the  most  important  stream,  rose  rather  sharply  to  the  hills  on  its  west  side,  but 
spread  out  widely  with  a  comparatively  flat  surface  for  some  distance  on  its 
eastern  side.  No  high  hills  separated  the  valley  of  Harford  Eun  from  that  of 
Jones  Falls;  indeed,  it  appears  that  these  two  streams  shared  the  same  valley 
over  much  of  their  courses  through  the  site  of  Baltimore.  At  a  comparatively 
short  distance  from  the  water-front,  the  east  side  of  the  valley  of  Harford  Eun 
rose  somewhat  gradually  to  meet  a  series  of  high  hills.  The  consequence  is  that 
with  the  grading  that  accompanied  the  development  of  the  city,  the  descent  to 
this  combined  valley,  over  a  certain  large  area,  is  abrupt  on  the  west  and  gradual 
on  the  east  side.  The  formation  above  described  in  the  higher  portions  of  the 
city  is  well  adapted  to  surface  drainage,  both  from  north  to  south  and  from 
east  to  west.  All  of  these  streams,  and  Jones  Falls  in  particular,  were  fre¬ 
quently  subject  to  overflow  after  very  heavy  rains,  and  as  the  city  grew  it  be¬ 
came  necessary  to  wall  their  banks  and  in  some  instances  to  straighten  their 
courses.  In  earlier  days  these  streams  were  of  great  importance  on  other  ac¬ 
counts;  both  G  wynn’s  and  Jones  Falls  were  used  to  turn  mills,  the  latter  being 
for  a  long  time  an  important  source  of  water-supply.  All  of  them  have  served 
continuously  as  storm-water  sewers  and  until  recent  years,  in  varying  degree, 
as  sanitary  sewers  as  well. 

Turning  now  to  the  water-front,  the  land  between  the  basin  and  the  first 
range  of  hills  to  the  north  was  comparatively  low,  hut  sloping  in  a  general  way 
from  north  to  south.  Near  the  mouths  of  the  streams,  along  the  shores  of  the 
basin  and  on  those  of  the  Middle  Branch  (Spring  Gardens),  there  were  wide 
marshes,  which  for  many  years  were  sources  of  nuisance.  Between  the  western 
side  of  the  basin  and  the  Patapsco  Eiver  there  projects  a  long  tongue  of  land, 
Whetstone  Point,  marked  at  its  base  by  a  towering  hill  (Federal  Hill)  and  along 
its  center  from  base  to  tip  by  a  ridge  from  each  side  of  which  the  surface  in¬ 
clines  to  the  water.  At  its  southern  extremity  is  situated  the  famous  Fort  Mc¬ 
Henry.  This  comparatively  narrow  strip  of  land  forms  the  southwestern  bound¬ 
ary  of  the  old  harbor,  and  from  early  days  its  eastern  side  has  been  the  seat  of 
important  docks  and  terminals,  as  well  as  shipbuilding  and  other  kindred  ac¬ 
tivities.  Opposite  a  point  of  land  (Locust  Point)  which  projects  from  about 
the  center  of  the  northern  shore  of  Whetstone  Point,  lies  Fell’s  Point,  the 
eastern  boundary  of  the  basin.  The  ground  here  was  uneven  and  in  general  low. 
To  the  west  and  at  the  base  of  this  point  empties  Harford  Eun.  In  early  times, 
before  the  basin  was  dredged  for  this  purpose,  FelFs  Point  was  the  head  of 
deep  water  and  the  docking-place  for  vessels  of  deep  draft.  Somewhat  to  the 
east  of  the  center  of  the  northern  shore  of  the  basin,  Jones  Falls  discharges. 
To  the  west  of  its  mouth  were  the  docks  and  piers  for  vessels  of  lighter  draft. 
Directly  opposite  Fort  McHenry  and  over  2  miles  southeast  of  FelFs  Point  is 
Lazaretto  Point,  long  the  seat  of  the  quarantine  station  and  of  the  old  lazaretto 
for  the  reception  of  goods  from  quarantined  vessels. 

To  the  east  and  west  of  the  city,  along  the  fall  line,  extends  a  narrow  and 
comparatively  low  ridge  containing  iron  ore,  wherefrom  the  ridge  derived  its 
name,  Mine  Banks.  To  the  south  of  the  Mine  Banks  and  on  each  side  of  the 
Patapsco  Eiver  the  land  is  in  general  relatively  flat,  with  numerous  inlets  and 
small  streams  and  was  formerly  marked  by  swamps  and  ponds.  From  the 
earliest  records  until  recent  years  this  region  was  a  hotbed  of  malaria,  and  in  it 
the  city’s  quarantine  hospitals  and  pest  houses  have  always  been  situated. 


PHYSICAL  AND  SOCIOLOGICAL  DATA  CONCERNING  BALTIMORE 


3 


SETTLEMENT  AND  GROWTH  IN  AREA. 

In  1729,  on  petition  of  the  inhabitants  of  Baltimore  County,  the  General 
Assembly  of  Maryland  provided  for  the  erection  of  a  town  upon  the  Patapsco 
Piver.  In  consequence,  in  September  1730,  60  acres  of  land,  situated  just  north 
of  Northwestern  Branch  of  the  Patapsco  River,  purchased  of  Charles  and 
Daniel  Carroll,  was  divided  by  commissioners  into  60  lots  of  nearly  equal  size, 
with  the  necessary  streets,  lanes,  and  alleys,  and  named  Baltimore  Town.  It  will 
be  noted  from  map  1  that  the  original  town  was  irregular  in  outline.  The  basin, 
since  considerably  narrowed  at  this  point  by  fillings,  formed  part  of  its  south¬ 
ern  boundary.  On  the  north  side  the  town  was  limited  by  the  first  considerable 
range  of  hills.  To  the  east  were  the  marshy  lowlands  bordering  the  mouth  of 
Jones  Falls.  Only  one  street  led  to  the  water  and  the  primitive  docks.  Through 
the  center  of  the  town  from  east  to  west  ran  the  principal  thoroughfare,  known 
as  Market  Street,  which  was  in  reality  the  road  connecting  Philadelphia  with 
the  southern  colonies.  The  avowed  reason  for  establishing  this  town  was  the 
necessity  for  an  additional  port  to  serve  the  surrounding  territory,  which  was 
fast  becoming  an  important  farming  country.  Until  1780  the  port  of  Baltimore 
Town  was  subsidiary  to  Annapolis. 

In  1732,  also  pursuant  to  act  of  the  General  Assembly,  Jones  Town  (see 
map  1)  was  erected  on  the  east  side  of  Jones  Falls  and  northeast  of  Baltimore 
Town.  It  consisted  of  20  lots  of  approximately  one-half  acre  each.  Jones  Town 
was  united  with  Baltimore  Town  in  1745.  As  these  original  settlements  grew, 
more  land  was  incorporated,  drained,  and  built  upon  on  both  sides  of  Jones 
Falls  to  the  basin. 

As  early  as  1730,  William  Fell,  a  shipwright,  had  settled  on  the  point  bear¬ 
ing  his  name.  With  the  expansion  of  commerce  and  shipbuilding,  the  region 
about  Fell’s  Point  was  rapidly  built  up,  and  in  1781  it,  too,  was  legally  joined  to 
Baltimore  Town. 

By  act  of  the  Legislature,  Baltimore  Town  became  Baltimore  City  on  De¬ 
cember  31,  1796.  It  will  be  observed  on  map  1  that  by  1801,  when  the  popu¬ 
lation  numbered  about  27,000,  extensive  changes  in  the  physical  characters  of 
the  situation  has  been  made.  Jones  Falls  in  its  lower  part  had  been  canalized 
with  masonry  walls  and  the  marshes  on  each  side  of  it  and  about  the  north  and 
west  sides  of  the  basin  filled  in  and  built  upon.  Extensive  docks  lined  the 
north  and  west  sides  of  the  basin  and  Fell’s  Point.  The  main  streets,  with  few 
exceptions,  ran  directly  north  and  south  and  east  and  west,  and  were  laid  out 
with  great  regularity.  This  same  regularity,  with  ample  width  for  most  streets, 
imposed  by  the  early  surveyors,  has  persisted  throughout  the  city’s  history.  The 
tendency  to  cling  to  the  water-front  and  to  expand  easterly  and  westerly  rather 
than  to  the  north  was  a  striking  feature  of  the  town  and  early  city.  This  has 
been  overcome  slowly  under  the  influence  of  railroads  and  modern  rapid  transit. 

In  1816,  by  annexation  of  territory  to  the  east,  west,  and  north,  the  corporate 
limits  were  considerably  increased.  The  city  now  included  13.2  square  miles. 
These  limits  remained  fixed  until  the  annexation  of  1888,  when  18.45  square 
miles  were  added.  By  the  annexation  of  1919,  the  city  lines  were  again  con¬ 
siderably  extended.  With  this  the  corporate  limits  embraced  91.93  square  miles. 
With  each  annexation  there  was  included  a  fringe  of  closely  built-up  areas,  im- 


4  PUBLIC  HEALTH  ADMINISTRATION-,  ETC.,  IN  BALTIMORE 

mediately  contiguous  to  the  old  city  lines,  and  extensive  outlying  areas  of 
village  and  rural  territory,  all  containing  manufacturing  and  other  industries, 
chiefly  located  along  the  streams  and  the  harbor. 

FACTORS  DETERMINING  THE  EXPANSION  IN  WEALTH 
AND  COMMERCIAL  IMPORTANCE. 

The  birth,  growth,  wealth,  and  civic  history  of  Baltimore  are  intimately  cor¬ 
related  with  water-borne  trade.  In  the  minds  of  the  petitioners  for  the  erection 
of  Baltimore  Town,  the  harbor  for  the  convenient  loading  of  tobacco,  then  the 
principal  staple  of  export  and  medium  of  exchange  for  manufactured  goods 
needed,  was  the  chief  consideration.  The  first  public  building  was  a  tobacco 
warehouse  situated  near  the  basin.  A  second  factor  of  prime  importance  was 
its  situation  on  the  Philadelphia  Road,  the  direct  land  route  between  New 
England,  New  York,  and  Philadelphia  and  the  rich  southern  colonies.  To 
the  land  side,  striking  natural  advantages  were  convenient  deposits  of  copper 
and  iron  ore  within  easy  reach,  abundant  timber  of  great  variety  and  of  fine 
quality  from  nearby  forests,  the  water-power  of  Jones  and  Gwynn’s  Falls  and 
of  the  Patapsco  River  and  other  streams,  fine  clay  for  brickmaking  within  her 
gates,  marble  and  other  building  stone  at  her  doors,  and  the  rich  agricultural 
lands  of  first  the  Piedmont  and  later  of  the  Ohio  Valley  for  grains,  flax,  meats, 
hides,  vegetables  and  similar  products.  Tobacco  from  the  tide-water  counties, 
and  fish  from  the  Chesapeake  Bay  could  be  readily  shipped  in  vessels. 

These  great  natural  advantages  were  cultivated  and  later  exploited  by  a 
rapidly  growing  band  of  adventurers  drawn  first  from  Maryland,  then  from  the 
British  Isles,  and  particularly  from  the  north  of  Ireland  and  Scotland,  and 
later  from  Virginia,  North  Carolina,  New  England,  New  York,  and  Penn¬ 
sylvania.  Of  considerable  importance  were  two  groups  of  French  extraction, 
the  Acadians  who  were  forcibly  transplanted  by  the  British  in  1756  and 
the  San  Domingan  refugees  who  arrived  in  1793.  The  arrival,  after  the  middle 
of  the  eighteenth  century,  of  a  few  people  of  German  extraction,  largely  from 
Pennsylvania,  who  were  trained  in  the  arts  of  spinning  and  weaving  and  in 
saddle  and  harness  making,  was  opportune. 

Despite  the  natural  advantages  and  the  adventurous  and  determined  popu¬ 
lation,  the  early  growth  and  progress  of  Baltimore  would  not  have  been  pos¬ 
sible  without  another  gift — a  genius  for  innovation  and  adaptation  in  transpor¬ 
tation  on  both  water  and  land.  The  genius  of  Baltimore  shipbuilders  developed 
the  famous  Baltimore  clipper,  the  fastest  cargo  and  fighting  wind-driven  vessel 
known  to  history.  On  the  same  model  they  built,  first  the  small  schooner  and 
later  the  larger  square-rigged  vessel,  the  bark,  the  brig,  and  their  modifications, 
and  the  full-rigged  ship.  These  two  types  differed  only  in  size  and  rig,  and 
their  startling  success  was  due  to  two  characteristics — the  design  of  the  hull 
and  the  tall  masts  carrying  an  unusual  area  of  sail.  This  model,  “  full  forward 
and  off  aft  ”  or  “  catfish  head  and  mackerel  tail,”  was  broader  and  higher  in 
the  bows  than  in  the  stem,  and  further  characterized  by  “  a  great  dead-rise  at 
her  mid-ship  section,  long,  easy,  convex  water-lines,  low  free-board  and  raking 
stern,  stern-post,  and  masts.”  This  design,  variously  ascribed  to  the  Chesapeake 
water-fowl, - to  Capt.  John  Smith’s  pinnace,  and  to  the  French  lugger,  speci¬ 
mens  of  which  visited  the  Chesapeake  during  the  Revolution,  marked  a  great 


X 


MAP  2. 


(From  Dr.  Th.  H.  Buckler.) 


MAP  2 


Wrn  'Vt/he#  StaveyvrfialtzmeTrv 


(From  Dr.  Th.  H.  Buckler.) 


PHYSICAL  AND  SOCIOLOGICAL  DATA  CONCERNING  BALTIMORE  5 


advance  over  the  ungainly  hulks  of  the  British  navy  and  merchant  marine. 
Owing  to  the  superiority  of  model,  excess  of  sail,  and  the  unusual  skill  and 
daring  of  their  skippers  and  crews,  these  vessels  outsailed  and  outmanoeuvred 
everything  afloat  and  laughed  at  blockading  fleets  in  both  home  and  foreign 
waters.  As  privateers  they  were  particularly  well  adapted,  and  great  wealth 
was  brought  to  Baltimore  in  prizes  and  prize-money  during  the  wars  with 
Britain.  During  the  wars  of  the  French  Revolution  and  of  Napoleon,  the  en¬ 
terprising  Baltimore  merchants  captured  with  these  vessels  a  large  part  of  the 
world’s  shipping  trade.  They  were  especially  active  in  the  West  Indian,  South 
American,  Mediterranean,  Spanish,  North  Sea,  and  Baltic  ports.  Some  reached 
out  to  the  Orient.  The  clipper-ship  era  lasted  until  the  opening  of  the  Suez 
Canal  in  1869.  This  ship,  which  sacrificed  cargo  capacity  to  speed,  was  espe¬ 
cially  serviceable  in  time  of  war,  for  perishable  and  manufactured  goods  of 
small  bulk  and  for  passengers.  It  finally  gave  way  to  the  coasting  schooner  and 
the  steamship,  and  had  almost  disappeared  by  1890.  One  of  the  most  famous, 
the  John  Gilpin ,  on  a  voyage  to  the  Orient  and  to  South  America,  sailed  some 
34,920  miles  at  the  average  rate  of  183  miles  a  day. 

With  the  settlement  and  development  of  the  country  in  her  rear,  first  nearby 
in  Maryland,  and  then  at  a  distance  to  and  over  the  Alleghenies,  land  transpor¬ 
tation  became  a  matter  of  great  importance  to  the  growing  city  and  its  tribu¬ 
tary  country.  For  a  time,  rough  wagon-roads  and  pack-trails  sufficed.  Late  in 
the  eighteenth  and  early  in  the  nineteenth  centuries  the  construction  of  wide 
turnpikes  to  strategic  centers  was  begun.  Thus,  the  Harford,  York,  Reister- 
town,  Frederick,  Washington,  Philadelphia,  and  other  roads  were  gradually  con¬ 
verted  into  broad  highways,  with  solid  foundations  and  coverings,  capable  of 
supporting  the  huge  u  Conestoga 99  wagons,  carrying  from  6,000  to  10,000 
pounds  and  drawn  by  teams  of  6  to  8  horses  or  mules. 

Of  great  significance  in  this  connection  was  the  opening  in  1818  of  the  Na¬ 
tional  Pike  from  Cumberland,  Maryland,  running  over  the  mountains  to  the 
Ohio  River.  This  national  thoroughfare  was  later  extended  to  Indiana,  Illinois, 
and  Missouri,  and,  until  the  passage  of  the  railroads  beyond  the  Allegheny 
Mountains  in  1852,  was  the  highway  from  East  to  West  for  the  mails  and  most 
of  the  travel  and  traffic.  The  improved  State  highway  from  Baltimore  to  Cum¬ 
berland  was  completed  in  time  for  Baltimore  to  take  full  advantage  of  the 
National  Pike  to  hold  and  to  extend  her  trade  with  the  West,  for  which  she  was 
the  natural  market.  As  early  as  1819  a  stage  route  was  established  to  Pitts¬ 
burgh  and  Wheeling. 

By  1823,  however,  her  supremacy  was  threatened  on  the  one  hand  by  Phila¬ 
delphia,  over  the  highways  built  through  Pennsylvania,  and  on  the  other  by 
New  York,  over  the  newly  opened  Erie  Canal.  Somewhat  later,  steamers  from 
New  Orleans  invaded  the  Ohio  River.  But  Baltimore  merchants  arose  to  the 
occasion  and  planned  and  executed  their  second  great  contribution  to  trans¬ 
portation,  this  time  by  land.  Casting  aside  the  first  considered  plan,  canals 
from  the  Susquehanna  and  the  Potomac  rivers,  they  decided  to  construct  a 
railroad  from  Baltimore  by  the  most  direct  route  to  some  point  on  the  Ohio 
River.  This  decision,  arrived  at  in  1827,  resulted  in  the  Baltimore  and  Ohio 
Railroad,  the  first  railroad  for  general  purposes.  Most  of  the  early  problems  of 
track  and  motive  power  were  solved  by  Baltimoreans.  The  new  road  was  open 
to  Point  of  Rocks,  72  miles,  in  1832,  to  Harpers  Ferry  in  1834,  to  Cumberland 


6 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


in  1842,  and  to  Wheeling  in  1852.  Connection  with  other  roads  opened  the 
Baltimore  and  Ohio  service  to  Cincinnati  and  St.  Louis  in  1857.  Meanwhile, 
at  Harper’s  Ferry,  connections  were  made  with  short  but  important  railroads 
leading  into  the  Valley  of  Virginia.  The  extension  to  Cumberland  made  avail¬ 
able  extensive  fields  of  cheap  steam  coal  to  Baltimore. 

Other  railroads  soon  followed.  The  Baltimore  and  Susquehanna,  begun  in 
1829,  the  Philadelphia,  Wilmington  and  Baltimore  and  the  Baltimore  and 
Potomac  started  about  1830,  financed  partly  at  least  by  Baltimore,  and  finally 
absorbed  into  the  Pennsylvania  Railroad  system,  connected  Baltimore  by  rail 
with  Philadelphia  and  New  York,  Pittsburgh  and  the  South.  The  Western 
Maryland,  running  more  centrally  through  the  State  than  the  others,  was  in¬ 
augurated  in  1852. 

By  1880,  with  the  extension  and  consolidation  of  trunk  lines  throughout 
the  country,  which  connect  with  all  the  great  Atlantic  seaports,  Baltimore  had 
lost  all  of  her  relative  advantages  except  one — her  position  nearer  to  the  West 
and  South  gave  shorter  hauls  and  thereby  a  favorable  differential  in  freight 
rates.  This,  with  highly  convenient  terminal  facilities,  and  Chesapeake,  coast¬ 
wise,  and  foreign  steamship  lines,  has  helped  to  preserve  her  importance  as  a 
port.  Advantageous  arrangements  made  early  between  the  Baltimore  and  Ohio 
Railroad  and  the  North  German  Lloyd  Steamship  Company  fostered  a  large 
trade  through  Bremen.  Of  late  years  cargo  steamship  lines  have  been  widely 
established,  but  particularly  with  British  ports. 

It  is  not  possible  to  follow  here  in  detail  all  the  shipping,  manufacturing, 
and  jobbing  activities  of  Baltimore.  It  was  natural  that  in  the  port  of  export 
and  import  of  a  rapidly  growing  and  developing  territory,  wholesale  jobbing 
should  become  and  remain  an  important  industry,  and  that  in  connection  with 
this  as  well  as  with  materials  near  at  hand  or  readily  obtainable,  an  enterprising 
population  should  develop  the  manufacture  of  iron,  copper,  chrome,  and  grain 
products ;  tobacco ;  wooden,  clay,  and  leather  ware ;  powder ;  cotton  and  woolen 
goods;  clothing,  hats,  shoes;  and  the  like.  Nor  is  it  strange  that  in  such  a  com¬ 
munity  banking  should  have  been  highly  developed  at  an  early  date,  and  that 
investments  in  transportation  and  manufacturing  enterprises  in  the  West  and 
South  have  made  high  returns. 

Certain  very  distinct  periods  of  growth  and  depression  characterize  Balti¬ 
more’s  history.  Until  1776  growth  was  comparatively  slow.  The  Revolution,  in 
which  she  played  a  conspicuous  part  by  both  land  and  sea,  found  Baltimore 
a  struggling  shipping  village  and  left  her  an  embryo  city  of  fearless  and  bold, 
yet  hard-headed,  inhabitants,  with  ships,  shipyards,  foundries,  mills,  and  un¬ 
rivaled  harbor,  and  with  a  rich  and  expanding  farming  community  in  the 
rear.  Freed  from  the  shackles  of  British  navigation  and  manufacturing  laws, 
within  the  next  30  years  her  growth  in  population  and  wealth  was  fabulous.  Be¬ 
tween  1790  and  1810  the  population  increased  nearly  250  per  cent.  Her  mer¬ 
chants  were  rich,  her  professional  men  in  medicine,  law,  and  theology  were 
distinguished,  her  general  population  was  prosperous,  well  housed,  and  fed, 
and  all  classes  were  contented.  With  food  in  great  variety  and  abundance  and 
of  the  best  quality,  to  be  had  cheap  at  convenient  markets,  with  famous  beers 
and  whiskies  made  locally,  and  every  facility  for  the  importation  of  foreign 
liquors,  material  conditions  were  very  attractive.  Life  was  characterized  by  an 
easy  and  genial  courtesy  and  hospitality. 


PHYSICAL  AND  SOCIOLOGICAL  DATA  CONCERNING  BALTIMORE  7 

During  the  embargoes  of  the  years  just  preceding  1812  and  the  period  of 
this  war,  when  the  Chesapeake  was  occupied  by  the  British  fleet,  but  especially 
as  the  result  of  the  succeeding  general  financial  collapse  and  the  consequent  de¬ 
cline  in  commerce  and  industry,  Baltimore  suffered  severely.  It  is  recorded  that 
in  1819,  20,000  people  were  out  of  employment.  From  1825  to  the  outbreak  of 
the  Civil  War  in  1861,  Baltimore  prospered  in  the  main.  During  this  period 
crowds  of  immigrants,  mainly  from  Ireland  and  Germany,  entered  at  the  port, 
and  many  settled  in  the  city. 

The  city  was  hard  hit  by  the  Civil  War,  for  coastwise  and  foreign  trade  was 
restricted,  southern  trade  was  interdicted,  and  trade  with  the  West  was  par¬ 
alyzed.  During  much  of  this  period  the  city  was  under  military  rule  and  oc¬ 
cupied  by  Federal  troops,  against  whom  a  large  and  influential  portion  of  the 
population  was  hostile.  Recovery  was  slow  and  not  until  after  1880  was  the 
comer  turned.  Since  1890  great  advances  have  been  made  in  trade  and  in 
wealth  from  many  sources.  A  great  fire  in  1904  destroyed  a  large  portion  of 
the  business  section.  In  connection  with  reconstruction,  which  was  soon  com¬ 
pleted,  extensive  improvements  to  the  docks  and  piers  of  the  basin  were 
carried  out. 

FORMS  OF  GOVERNMENT. 

Baltimore  Town  was  governed  by  commissioners,  sometimes  appointed  by 
State  authority  and  sometimes  elected  on  a  restricted  franchise.  With  few  ex¬ 
ceptions,  the  laws  under  which  the  town  was  governed  were  passed  by  the 
Colonial  Assembly  or  by  the  Legislature  of  the  State.  Granted  a  charter  in 
1796,  Baltimore  was  incorporated  as  a  city  January  1,  1797,  under  the  title  of 
the  Mayor  and  City  Council  of  Baltimore  City.  Since  this  date,  but  with 
several  more  liberal  charters  granted  at  various  times,  the  government  has  been 
carried  on  by  a  mayor,  a  bicameral  city  council,  a  judiciary,  and  a  local  mag¬ 
istracy.  For  civic  purposes,  the  political  subdivisions  are  wards.  For  nearly  half 
a  century  the  control  of  the  police  force  has  been  in  the  hands  of  commissioners 
appointed  by  the  governor  of  the  State.  Since  the  charter  of  1900,  the  re¬ 
sponsibility  of  the  city  government  has  been  concentrated  in  the  hands  of  the 
mayor  and  the  board  of  estimates,  consisting  of  the  mayor  and  the  heads  of 
departments,  who  are,  with  several  important  exceptions,  appointed  by  the 
mayor,  and  subject  to  confirmation  by  the  council.  The  schools,  the  park  sys¬ 
tem,  the  jail,  the  harbor,  the  city  charities,  and  the  sinking  fund  are  conducted 
by  special  boards  composed  of  members  appointed  by  the  mayor  for  definite  and 
overlapping  terms.  Membership  on  these  boards  is  a  mark  of  distinction  and 
members  serve  without  salary.  Members  of  commissions  for  various  other  pur¬ 
poses  receive  salaries.  The  board  of  estimates  holds  the  purse  strings  and,  to¬ 
gether  with  the  mayor,  is  the  real  power.  On  the  whole  this  system  has  worked 
well  and  in  many  departments  of  the  city  government  has  given  reasonably  ef¬ 
ficient  sendee. 

METEOROLOGY. 

The  climate  of  Baltimore  is  exceptionally  fine,  with  an  abundance  of  sun¬ 
shine  and  rain  and  a  comparatively  low  relative  humidity.  As  a  rule,  severe 
storms  are  infrequent,  prolonged  droughts  are  rare,  and  extreme  changes  in 


8 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


temperature  develop  gradually.  These  characteristics  are  due  in  part  to  the  tem¬ 
pering  influence  of  the  Chesapeake  Bay  and  in  part  to  the  fact  that  of  the  three 
great  transcontinental  storm  areas,  two  pass  well  to  the  north,  while  the  one 
following  the  southern  course  is  moderated  in  its  passage  over  the  Southern 
States  before  it  reaches  the  city. 

The  annual  averages  for  temperature,  precipitation,  and  relative  humidity 
are  55.5°  F.,  43.18  inches,  and  69  per  cent,  respectively.  As  on  an  average,  the 
sun  shines  some  portion  of  the  day  on  321  days  in  the  year,  gloomy  weather  is  of 
rare  occurrence.  However,  days  with  100  per  cent  sunshine  are  uncommon  at 
any  season  of  the  year,  for  on  typical  days  the  sky  is  partly  covered  with  clouds. 
In  winter  the  sunshine  is  53  per  cent  of  the  possible  amount  and  the  relative 
humidity  is  only  about  70  per  cent.  While  high  winds  are  rare,  except  in  con¬ 
nection  with  occasional  storms,  the  air  in  both  summer  and  winter  is  usually  in 
gentle  motion.  At  all  seasons,  in  association  with  calm  or  light  winds  from  the 
direction  of  the  water,  fogs  occur.  They  are  rarely  dense,  and  are  usually  of 
short  duration. 

The  temperature  is  mild  in  winter,  moderate  in  spring  and  autumn,  and 
warm  in  summer.  In  table  1,  compiled  from  data  furnished  by  the  local 


Table  1. — Average  monthly  temperatures  in  degrees  Fahrenheit  and  the  average  pre¬ 
cipitation  in  inches  for  the  period  1871-1920  and  relative  humidity  for  the  period 
1888-1921,  inclusive. 


Month. 

Temp. 

Precip¬ 

itation. 

Relative 
humidity  at 

8  a.m.,  12  noon, 
and  8  p.  m. 

Month. 

Temp. 

Precip¬ 

itation. 

Relative 
humidity  at 

8  a.m.,  12  noon, 
and  8  p.  m. 

Jan . 

34. 

3.22 

p.  ct. 

71 

July  . 

77.4 

4.82 

•  p.  ct. 

69 

Feb . 

35.4 

3.51 

68 

Aug . 

75.5 

4.21 

72 

Mar . 

42.3 

3.88 

66 

Sept . 

68.5 

3.85 

74 

Apr . 

53.6 

3.27 

62 

Oct . 

58.2 

3.02 

71 

May  . 

64.4 

3.56 

66 

Nov . 

46.3 

2.92 

69 

June  . 

72.7 

3.84 

68 

Dec . 

37.2 

3.08 

70 

Average  annual:  Temperature  55.5°  F.  Precipitation  43.18  inches.  Humidity  69%. 


office  of  the  United  States  Weather  Bureau,  are  given  the  average  temperature, 
precipitation,  and  humidity  by  months.  It  will  be  noted  that  while  January  is 
the  month  of  lowest  and  July  the  month  of  the  highest  temperature,  the  dif¬ 
ference  between  the  average  monthly  temperatures  of  December,  January,  and 
February  and  between  those  of  June,  July,  and  August,  is  comparatively  slight. 
The  average  temperature  is  above  60°  F.  between  'May  and  September,  in¬ 
clusive,  and  below  this  level  during  the  remainder  of  the  year.  Excessively  high 
temperatures  are  occasionally  recorded  in  both  May  and  October.  On  the  whole 
the  ascent  of  the  temperature  from  the  low  point  in  January  to  the  peak  in 
July,  and  the  descent  through  the  rest  of  the  year,  follow  rather  regular  gra¬ 
dients. 

The  curve  of  the  rainfall  by  months  is  not  so  regular.  During  February  and 
March  the  rainfall  increases  in  amount  decidedly  over  the  level  for  January, 
falls  significantly  in  April,  and  then  rises  gradually  to  its  peak  in  July,  the  hot¬ 
test  month.  By  September  the  rainfall  has  decreased  to  the  level  of  June,  and 


PHYSICAL  AND  SOCIOLOGICAL  DATA  CONCERNING  BALTIMORE  9 


during  October,  November,  and  December,  the  driest  months  of  the  year,  the 
monthly  rainfall  varies  hardly  at  all.  Measured  in  inches  by  season,  the  rain¬ 
fall  averages  3,  3.53,  3.55,  and  4.25,  respectively,  for  each  month  of  the  fall, 
winter,  spring,  and  summer.  Thus  it  appears  that  the  monthly  rainfall  is  about 
the  same  in  winter  and  spring,  but  in  the  summer  months  it  is  much  higher  and 
in  the  fall  months  much  lower,  than  in  the  rest  of  the  year. 

Humidity  is  lowest  in  April  and  highest  in  September.  In  July,  the  month 
of  the  highest  temperature  and  rainfall,  and  in  November,  a  cool  month  with 
the  smallest  rainfall  of  the  year,  humidity  stands  at  the  level  of  its  average  for 
the  year.  From  71  in  January  it  declines  progressively  during  February  and 
March  to  62  in  April.  Over  the  succeeding  five  months  it  rises  steadily  to  74 
in  September  and  remains  relatively  high,  71,  69,  and  70,  in  October,  Novem¬ 
ber,  and  December,  respectively. 

Data  concerning  direction  of  the  wind  are  given  in  table  2.  For  the  year  as 


Table  2. — Direction  of  the  wind  at  Baltimore  hy  seasons  of  the  year ,  according  to  per¬ 
centages  based  upon  hourly  observations  and  averaged  for  11  years.  (U.  S.  Weather 
Bureau.) 


Season. 

* 

NW. 

w 

fc 

GO 

GO 

w 

GO 

w 

£ 

ta 

is 

& 

& 

w 

CO 

•a 

GO 

GO 

Off  land. 

Off  water. 

SW.,  W.,  NW., 
N.,  NE.,  &  E. 

S.  &  SE. 

Winter  .... 

16 

18 

11 

12 

20 

9 

5 

9 

45 

41 

72 

28 

Spring  .... 

15 

18 

11 

14 

15 

13 

7 

7 

44 

42 

73 

27 

Summer  . . . 

14 

12 

10 

21 

18 

13 

7 

5 

36 

52 

66 

34 

Autumn  . . . 

16 

16 

10 

15 

17 

11 

7 

8 

42 

43 

74 

26 

Year  . 

15 

16 

10 

16 

18 

12 

6 

7 

41 

46 

72 

28 

a  whole,  the  wind  blows  from  the  northern  segment  for  41  per  cent  and  from 
the  southern  segment  46  per  cent  of  the  time.  During  the  remaining  13  per 
cent  of  the  time  due  east  and  due  west  winds  are  almost  equal  in  frequency.  In 
winter,  spring,  and  autumn,  northerly  and  due  westerly  winds  occur  with 
greater  frequency  than  do  southerly  and  due  easterly  winds.  In  the  summer 
months  conditions  are  reversed,  and  the  wind  blows  from  a  generally  southerly 
direction  for  52  per  cent  and  from  the  northerly  segment  for  only  36  per  cent 
of  the  time,  and  decidedly  less  frequently  from  due  west  than  from  due  east. 
These  differences  of  wind  direction  in  these  two  seasons  are  owing  very  largely 
to  the  higher  percentage  of  due  south  winds  and  a  lower  percentage  of  due 
north,  northwest  and  west  winds  in  summer  as  compared  with  winter.  This  is 
a  point  of  considerable  importance,  for  as  a  general  rule  winds  from  the  north¬ 
erly  segment  are  associated  with  cold  or  relatively  cool  weather  and  those  from 
the  south  with  warm  or  temperate  weather.  There  is  comparatively  little  sea¬ 
sonal  variation  in  the  frequency  of  northeast  winds,  which  are  often  associated 
with  rain  at  all  seasons.  The  last  two  columns  of  the  table  show  the  occurrence 
of  winds  in  relation  to  the  river  and  Chesapeake  Bay  near  the  city.  It  will  be 
observed  that  in  summer  the  percentage  of  frequency  of  land  winds  falls  and 
the  percentage  of  frequency  of  winds  from  over  the  water  rises  decidedly  as  com¬ 
pared  with  what  obtains  at  other  seasons. 


10 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


The  average  hourly  wind  velocity  (table  3)  is  6.4  miles.  From  June  to  De¬ 
cember  the  wind  velocity  is  below  and  from  January  to  May  is  above  the  aver¬ 
age  for  the  year.  The  highest  velocities  occur  in  February,  March,  and  April, 
and  the  lowest  in  June,  July,  and  August. 

The  mean  annual  barometric  pressure  (table  3)  is  30.05  inches.  Though  the 
extremes  are  not  great  the  highest  monthly  pressures  occur  in  the  colder  months 
and  the  lowest  in  the  warmer  months  of  the  year. 


Table  3. — Average  hourly  wind  velocity  (51  years)  in  miles ,  and  the  mean  sea-level 
barometric  pressure  (48  years)  in  inches.  (U.  S.  Weather  Bureau.) 


Month. 

Wind 

velocity. 

Barometric 

pressure. 

Month. 

Wind 

velocity. 

Barometric 

pressure. 

Jan . 

6.5 

30.13 

July  . 

5.9 

29.98 

Feb . 

7.1 

30.10 

Aug . 

5.4 

30.01 

Mar . 

7.5 

30.04 

Sept . 

5.6 

30.08 

Apr . 

7.4 

30.00 

Oct . 

6.0 

30.11 

May  . 

6.6 

29.98 

Nov . 

6.2 

30.10 

J une  . 

6.2 

29.99 

Dec . 

6.3 

30.12 

These  composite  pictures  of  the  general  meteorological  phenomena  give,  after 
all,  an  incomplete  idea  of  the  actual  conditions,  particularly  in  summer.  The 
hills  which  surround  the  city  on  parts  of  three  sides  and  the  nearby  large 
bodies  of  water  to  the  south  temper  the  winter  in  the  city.  The  hills  and  valleys 
of  the  city  itself  are  in  general  favorable  for  the  circulation  of  air  in  the 
summer.  In  the  main,  the  weather  of  spring,  autumn,  most  of  the  winter,  and 
part  of  the  summer  is  ideal.  Periods  of  two  to  three  days  to  a  week  or  two  in 
summer  characterized  by  an  excess  of  heat  associated  with  a  high  degree  of 
humidity  are  not  of  infrequent  occurrence.  In  these  periods  official  afternoon 
temperatures  of  over  90°  are  commonly  recorded,  and  in  most  of  the  built-up 
and  in  all  of  the  low-lying  parts  of  the  city,  particularly  in  the  business  and 
manufacturing  sections,  the  temperature  registers  much  higher  levels.  On  these 
*  occasions,  when,  in  the  absence  of  breeze,  the  pavements  and  brick  houses  re¬ 
tain  at  night  the  heat  absorbed  during  the  day,  in  many  parts  of  the  city  the 
atmosphere  is  stifling.  Under  these  conditions,  while  relatively  few  deaths  are 
ascribed  definitely  to  heat-stroke,  the  death-rate  from  various  causes,  particu¬ 
larly  among  infants  and  the  aged,  rises  significantly.  Mortality  from  causes 
peculiar  to  early  infancy  and  from  gastro-intestinal  affections  of  individuals 
under  2  years  of  age  commonly  reach  the  highest  level  in  these  periods.  On 
the  other  hand,  the  heat  of  summer  is  usually  mitigated  by  clouds,  refreshing 
breezes,  by  day  and  night,  and  frequent  thunder-showers.  In  the  higher  portions 
of  the  city,  and  particularly  in  the  openly  built  sections  in  the  hilly  districts, 
excessively  oppressive  heat  throughout  the  24  hours  is  rare.  The  comparatively 
mild  and  short  winter  season  exercises  an  important  effect  upon  employment  in 
all  out-of-door  work  and  especially  in  construction  activities.  There  are 
relatively  few  days  when  workers  are  debarred  from  plying  their  trades,  and  on 
this  account  seasonal  lay  offs  are  of  less  importance  than  in  less  genial  climates. 


Chapter  II. 


Physicians  and  medical  education;  Hospitals  and  dispensaries;  Chari¬ 
ties;  Dwellings;  Schools. 

PHYSICIANS. 

Medicine  and  medical  men  have  played  an  unusually  prominent  part  in  the 
life  and  development  of  Baltimore.  Two  of  the  five  commissioners  appointed 
to  lay  out  the  town  were  physicians,  Drs.  George  Buchanan  and  George  Walker. 
Three  years  later,  the  latter  assisted  in  the  founding  of  Jones  Town,  across 
Jones  Falls,  afterwards  united  with  Baltimore  Town.  The  four  physicians 
in  practice  in  1756  included  Drs.  Henry  Stevenson  and  Charles  Wiessenthal,  the 
first  distinguished  later  as  one  of  the  foremost  inoculators  in  America  against 
smallpox,  and  the  latter,  universally  revered  as  the  Sydenham  of  Baltimore 
Town.  From  figures  given  by  Quinan,  the  number  of  physicians  resident  in 
early  Baltimore  and  their  proportion  in  the  population  in  different  years  were 
as  follows:  1776,  19,  or  1:355;  1782,  23,  or  1:347;  1790,  30,  or  1:450; 
1799,  34,  or  1 :  617;  1810,  46,  or  1 :  1,012. 

In  connection  with  the  rapid  growth  of  the  town  and  State  in  wealth  and 
population  during  the  last  decade  of  the  eighteenth  century,  there  was  an 
extensive  invasion  of  medical  quacks.  In  order  to  control  these,  a  movement 
begun  by  Dr.  Charles  Wiessenthal  of  Baltimore  and  Dr.  John  Hall  of  Frederick 
resulted  in  the  establishment  in  Baltimore  of  a  medical  society  in  1785,  and, 
in  1799,  the  Medical  and  Chirurgical  Faculty  of  Maryland  was  granted  the 
right  by  charter  from  the  legislature  to  license  candidates  for  medical  prac¬ 
tice  after  “  a  full  examination  before  the  board  of  examiners,”  or  “  in  lieu 
thereof  presenting  a  satisfactory  diploma.”  The  101  incorporators,  from  all 
parts  of  the  State,  represented  the  best  elements  of  the  State  and  town  and  in¬ 
cluded  men  trained  in  the  medical  schools  of  Leyden,  Paris,  London,  Oxford, 
Edinburgh,  Glasgow,  Aberdeen,  and  Dublin;  but  as  late  as  1807,  of  the  241 
members  of  the  faculty,  only  17  per  cent  had  medical  degrees.  Among  the 
Baltimore  physicians  at  the  opening  of  the  nineteenth  century  were  men  with 
names  then  and  ever  since  of  the  highest  standing  in  the  city  and  State.  The 
Medical  and  Chirurgical  Faculty,  in  order  of  its  foundation  the  seventh  State 
medical  society,  has  been  closely  identified  throughout  its  history  with  medical 
education  and  public-health  measures. 

The  faculty  indorsed  vaccination  against  smallpox  in  1802,  appointed  com¬ 
mittees  of  investigation  and  advice  to  the  health  department  during  the  early 
yellow-fever  epidemics,  especially  that  of  1819,  advised  the  mayor  and  the  city 
council  in  regard  to  the  health  ordinances  in  1820  and  in  other  years,  urged 
the  appointment  of  public  vaccinators  in  1821  and  the  establishment  of  a  State 
vaccine  agency  in  1864,  and  has  taken  an  active  part  in  securing  acts  of  the 
legislature  in  regard  to  public  health.  The  faculty  did  not  long  retain  com¬ 
plete  control  over  medical  practice,  for,  under  pressure  of  medical  charlatanism 
2 


11 


12  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  1ST  BALTIMORE 

in  the  rapidly  growing  community,  the  powers  of  licensure  after  examination 
were  withdrawn  by  the  legislature,  not  to  be  regranted  until  1892.  Thus,  for 
many  years  its  power  in  this  direction  was  limited  to  the  influence  of  the  high 
standard  of  medical  ethics  which  it  set  up  and  consistently  maintained.  Bal¬ 
timore  has  had  its  quota  of  societies  and  clubs  devoted  to  the  encouragement  of 
general  medicine,  surgery,  obstetrics  and  gynecology,  pathology,  and  various 
other  departments  of  medicine,  many  of  them  associated  directly  or  indirectly 
with  the  Medical  and  Chirurgical  Faculty.  However,  as  it  will  appear  later,  the 
leading  Baltimore  physicians  have  ever  been  disposed  to  do  their  own  think¬ 
ing  and  to  be  guided  by  their  own  observations.  In  the  later  years  of  the 
eighteenth  and  in  the  earlier  years  of  the  nineteenth  centuries  they  were  in¬ 
clined  to  repudiate  the  domination  of  contemporary  British  in  medicine  as  in 
politics.  Rush,  the  outstanding  figure  of  American  medicine  in  his  day,  seems 
to  have  carried  but  little  weight  with  them.  In  later  years  Philadelphia,  New 
York,  and  Boston  were  heard  with  respect.  By  the  rising  French  school  of  the 
first  half  of  the  nineteenth  century,  and  in  particular  by  Laennec,  Andral, 
Louis,  Bretonneau,  Rielliez,  Barthez,  Trousseau,  and  Charcot,  they  were  slowly 
but  markedly  influenced.  Not  until  after  the  intensive  development  of  patho¬ 
logical  anatomy  and  of  bacteriology  in  Germany  were  Baltimore  physicians 
much  affected  by  the  medical  teachings  of  that  country. 

MEDICAL  EDUCATION. 

The  first  medical  teaching  of  a  formal  kind  in  Baltimore  was  given  during 
the  winter  of  1789-90  by  Dr.  George  Buchanan  in  diseases  of  women  and  chil¬ 
dren  and  by  Dr.  Andrew  Wiessenthal  in  anatomy,  physiology,  pathology,  and 
operative  surgery.  The  next  year  chemistry  and  materia  medica  were  added 
to  the  curriculum  of  Dr.  Wiessenthal’s  school.  A  program  was  issued,  during 
the  ensuing  winter,  of  a  medical  faculty,  consisting  of  Dr.  Andrew  Wiessenthal, 
anatomy;  Dr.  George  Brown,  practice  of  medicine;  Dr.  Lyde  Goodwin,  sur¬ 
gery;  Dr.  S.  Y.  Coale,  chemistry  and  materia  medica;  and  Dr.  George  Buch¬ 
anan,  obstetrics.  Drs.  John  B.  Davidge,  James  Cocke,  and  John  Shaw  soon 
afterwards  offered  courses  of  lectures. 

An  important  part  of  the  original  plan  of  the  organizers  of  the  Medical  and 
Chirurgical  Faculty  was  a  school  of  medicine  under  the  supervision  of  the  or¬ 
ganized  profession,  and  in  his  address  in  1801,  the  president  of  the  faculty 
urged  the  adoption  of  a  plan  to  organize  such  a  school  in  Baltimore.  In  1803, 
Dr.  John  B.  Davidge,  with  Dr.  George  Brown  and  others,  was  appointed  to  con¬ 
sider  a  plan  for  the  proposed  medical  school,  but  it  was  not  until  December  18, 
1807,  that  the  College  of  Medicine  of  Maryland,  the  fourth  in  the  United  States, 
was  incorporated,  with  six  professors.  The  cornerstone  of  the  new  college 
building,  a  handsome  and,  for  those  days,  commodious  structure,  was  laid  in 
1811,  and  in  1812  the  college  became  the  medical  department  of  the  University 
of  Maryland.  Among  the  early  professors,  John  B.  Davidge  and  Nathaniel 
Potter  stand  out  as  erudite  and  forceful  men,  who  by  their  teachings  and  writ¬ 
ings  profoundly  influenced  the  attitude  of  their  contemporaries  on  questions 
of  public  health.  The  school,  under  the  control  of  regents,  was  conducted  with 
dignity  and  due  sense  of  responsibility  to  the  profession  and  to  the  community. 
An  important  reason  for  the  great  reputation  it  finally  won  was  the  fact  that 


PHYSICAL  AND  SOCIOLOGICAL  DATA  CONCERNING  BALTIMORE  13 


the  authorities  did  not  hesitate  to  go  out  of  town  for  teachers.  In  1820,  Gran¬ 
ville  Sharp  Patterson  and,  in  1827,  Nathan  R.  Smith  were  called  to  fill  the 
chair  of  surgery.  Elisha  Bartlett  was  called  to  succeed  Potter  as  professor  of 
medicine  in  1844,  and  he,  in  his  turn,  was  succeeded  by  William  Power,  who, 
though  a  native  of  Baltimore,  had  spent  three  years  with  Louis  in  Paris.  Until 
about  1890  this  school  stood  among  the  strongest  medical  schools  of  the  country 
in  strength  of  the  faculty  and  methods  of  teaching,  and  it  fell  to  a  secondary 
place  only  when  it  failed  to  establish  strongly  manned  and  well-equipped  lab¬ 
oratories  of  anatomy,  physiology,  and  pathology.  Besides  the  Baltimore  In¬ 
firmary,  it  had  abundant  clinical  material  at  other  hospitals. 

In  1827,  though  there  was  no  need  for  it,  an  ambitious  group  of  medical 
men,  led  by  Horatio  G.  Jameson,  a  man  of  force  and  talent,  established  The 
Washington  Medical  College,  as  the  medical  department  of  Washington  Col¬ 
lege,  Pennsylvania.  This  school,  leading  a  precarious  existence  for  many 
years,  was  succeeded  by  a  proprietary  school,  The  College  of  Physicians  and  Sur¬ 
geons,  at  which  some  able  men  gave  lectures  and  developed  ward  and  laboratory 
teaching  to  a  somewhat  higher  degree  than  at  the  University  of  Maryland.  It 
used  the  clinical  material  of  Mercy  and  other  hospitals. 

Later  (1882),  a  second  proprietary  school,  The  Baltimore  Medical  College, 
was  founded  by  another  group  of  ambitious  men,  for  whom  no  positions  offered 
in  the  other  two  schools.  With  more  modern  buildings  and  stressing  laboratory 
teaching,  perhaps  more  than  its  rivals,  this  school  drew  a  large  number  of 
students. 

Lacking  endowments,  without  reputation  in  medical  research,  unable  to 
exert  those  other  qualities  that  draw  gold  to  the  support  of  medical  education, 
and  their  receipts  cut  by  the  decline  in  the  number  of  students — due  to  the 
higher  entrance,  teaching,  and  licensure  requirements  demanded  by  the  State 
examining  boards,  all  three  of  these  schools,  about  1910,  were  not  only  unable  to 
advance,  but  found  their  existence  precarious.  First  the  Baltimore  Medical 
College  and  then  the  College  of  Physicians  and  Surgeons  fused  with  the  older 
school. 

For  some  years  a  woman’s  medical  college,  established  in  1882,  led  an  uncer¬ 
tain  life  and  perished  because  means  were  not  obtainable  to  continue  a  credit¬ 
able  existence. 

Between  1870  and  1885  there  arose  several  obscure  medical  schools  with  pre¬ 
tentious  names,  all  of  them  with  the  most  primitive  excuses  for  laboratory  and 
hospital  facilities. 

All  of  these  schools,  except  the  University  of  Maryland,  were  founded  by 
physicians  ambitious  for  fees,  but  above  all  for  the  professorial  title  and  con¬ 
sulting  practice,  and  throughout  their  existence  they  were  proprietary.  The 
university,  a  legitimate  child  of  the  State,  was  established  by  the  medical  pro¬ 
fession  to  fill  a  real  need  in  medical  education  and  was  placed  under  the  gov¬ 
ernment  of  a  board  of  regents,  chosen,  at  least  at  first,  from  and  by  the  Medical 
and  Chirurgical  Faculty.  For  the  first  70  years  of  its  existence,  in  its  stand¬ 
ards  of  ethics,  teaching,  and  examination,  it  reflected  truthfully  the  ideals  of 
the  best  and  brightest  of  the  profession  of  the  State.  Since  1895  in  teaching  it 
has  not,  in  a  relative  sense,  maintained  this  position.  The  two  other  leading 
schools  and  the  Woman’s  Medical  College  had  on  their  faculties  during  their 
whole  existence  many  men  of  the  highest  standing  in  the  community  and  of 


14 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


considerable  professional  attainment,  and  especially  during  the  past  20  years, 
often  at  least,  the  equals  in  ability  of  the  holders  of  their  respective  chairs  in 
the  University  of  Maryland.  While,  as  a  general  rule,  all  these  schools  drew 
the  bulk  of  their  students  from  other  States,  and  most  of  the  better  class  of 
Maryland  students  attended  the  university,  a  not  inconsiderable  number  of 
non-resident  graduates  of  all  of  them  settled  in  Baltimore,  and  many  Balti¬ 
more  students  of  deficient  education  graduated  from  the  lowest  type  of  pro¬ 
prietary  schools — the  diploma  mills  of  the  worst  type.  As  a  consequence  of  the 
relatively  low  standards  of  the  four  schools  of  the  better  type  and  of  the  de¬ 
based  standards  of  those  of  the  poorest  type,  between  1875  and  1905,  the  medi¬ 
cal  profession  was  recruited  by  large  numbers  of  relatively  defective,  ranging 
from  bright  men  of  college  education  and  trained  in  the  fundamental  sciences 
but  handicapped  by  poor  facilities  and  opportunities  offered  by  the  better 
schools,  through  the  gamut  to  the  mentally  slow  and  dull,  whose  opportunities 
in  both  preliminary  and  medical  education  were  scandalously  deficient.  Medi¬ 
cal  practitioners  of  the  same  grades,  botli  residents  and  non-residents,  who  had 
attended  schools  of  all  orders  elsewhere,  some  of  them  graduates  of  foreign 
universities,  completed  the  list.  As  a  result  of  all  these  factors,  there  was  added 
to  the  Baltimore  profession,  during  the  period  of  greatest  activity  of  the  pro¬ 
prietary  schools,  a  considerable  group  of  physicians  deficient  not  only  in  the 
knowledge  of  physiology  and  pathology  and  the  natural  history  of  disease,  but 
in  modern  methods  of  diagnosis  and  particularly  in  the  principles  underlying 
protective  vaccination  and  serum  therapy,  defects  which  have  left  them  a  prey 
to  the  guile  of  pseudo-scientific  manufacturers  of  drugs  and  biological  products. 
One  of  the  most  striking  evils  of  medical  education  in  Baltimore  during  this 
period  was  a  lack  of  practical  teaching  in  obstetrics  and  in  infant  and  child 
feeding. 

Throughout  its  whole  history  from  1780  to  at  least  1890,  except  during  a 
few  years  when  the  Medical  and  Chirurgical  Faculty  had  control  of  medical 
licensure,  the  city  had  its  share  of  advertising  quacks  and  other  medical  char¬ 
latans.  That  all  these  untoward  factors  have  made  distinct  contributions  to 
the  general  death-rate  and  to  the  rates  for  certain  diseases  is  beyond  ques¬ 
tion.  Nevertheless,  it  is  probable  that  during  this  period  until  1895  the  general 
level  of  medical  practice  in  Baltimore  was  at  least  as  high  as  that  of  the  At¬ 
lantic  seaboard  cities  and  much  higher  than  that  of  cities  to  the  west  and  south. 
This  state  of  affairs  was  due  partly  to  a  few  forceful  teachers  in  each  genera¬ 
tion,  to  the  natural  ability  of  those  who  came  to  the  top,  and  to  the  fact  that 
on  account  of  defects  in  their  home  teaching,  many  sought  postgraduate  in¬ 
struction  abroad. 

After  the  founding  of  the  Medical  and  Chirurgical  Faculty  and  of  the  Uni¬ 
versity  of  Maryland  under  its  auspices,  the  most  profoundly  important  bene¬ 
ficial  influence  upon  medicine  in  Baltimore  is  that  of  the  Johns  Hopkins  Uni¬ 
versity,  opened  in  1876,  the  hospital  in  1889,  and  the  medical  school  in  1893. 
The  influence  of  scientific  investigation  and  laboratory  teaching  in  physics 
under  Rowland,  chemistry  under  Remsen,  zoology  under  Brooks,  and  physiology 
and  histology  under  Martin  was  well  established  by  1880.  As  these  men  entered 
freely  into  the  public  and  social  life  of  the  community,  the  influence  of  their 
ideas  and  methods  and  wide  knowledge  rapidly  spread  in  intellectual  circles, 


PHYSICAL  AND  SOCIOLOGICAL  DATA  CONCERNING  BALTIMORE  15 

of  which  the  leading  physicians  formed  an  important  part.  Young  men  going 
into  medicine  took  their  courses  and  young  medical  graduates  sought  and  ob¬ 
tained  admission  into  their  classes,  particularly  in  chemistry  and  physiology 
and  histology.  Here  Abbott,  Councilman,  and  Booker,  as  postgraduate  stu¬ 
dents,  got  their  first  training  in  microscopy;  here  also  Sternberg  did  his  early 
work  in  bacteriology. 

Thus,  the  time  and  the  settings  were  ready  for  the  advent  in  1884  of  Welch, 
whose  first  courses  were  given  in  the  biological  laboratory.  The  brighter  of 
the  younger  and  many  even  of  the  established  physicians  during  the  next  10 
or  15  years  enrolled  themselves  in  the  courses  in  bacteriology  and  pathological 
anatomy  offered  by  Welch  and  his  associates  in  his  pathological  laboratory. 
Fortunately,  Welch's  courses  were  also  opened  to  those  undergraduates  of  the 
Johns  Hopkins  University  who  expected  to  study  medicine.  By  these  means, 
interest  in  the  fundamental  sciences  in  Baltimore  was  revived  and  rekindled. 
Young  men  entering  medicine  had  opportunity  to  pursue  them,  and  gradu¬ 
ates  in  medicine  as  well  were  enabled  to  make  up  their  deficiencies  in  physiology, 
microscopic  anatomy,  micro-parasitology,  pathological  anatomy,  and  general 
pathology.  From  these  springs,  medicine  in  Baltimore  drank  a  revivifying 
draught.  By  1890,  Welch's  students  comprised  directly  or  indirectly  the  whole 
medical  profession  of  Baltimore,  for  there  were  few  so  ignorant  or  so  fossilized 
that  they  could  not  absorb  something  of  knowledge  so  simply  diffused  and  im¬ 
parted  by  this  clear-headed,  impelling  master,  whose  kindly  manner  reassured 
the  meek  and  abashed  the  arrogant.  Whether  it  was  the  student  who  in  the 
laboratory  was  encouraged  to  utilize  the  ample  material,  or  the  experimenter, 
to  teach  himself,  or  the  physician  in  professional  or  social  gatherings  and 
in  visits  of  consultation  at  his  home,  all  took  away  a  new  conception  of  medicine 
and  the  inspiration  to  follow  it.  The  most  valuable  service  rendered  at  this 
time  was  to  the  brighter  young  medical  graduates,  who  threw  aside  the  medical 
text-books  of  the  day  and  read  in  their  stead  the  masters  in  medicine  and  the 
better  articles  of  the  current  literature,  and,  freed  from  the  dogmas  and  gener¬ 
alities  of  the  schools  and  imbued  with  the  spirit  of  observation,  experiment,  and 
critical  analysis,  thought  for  themselves. 

The  next  important  step  was  the  opening  of  the  Johns  Hopkins  Hospital  in 
1889,  when  the  local  medical  profession  received  a  salutary  shock  when  made 
to  realize  that  no  one  of  them  had  so  cultivated  the  medical  sciences  as  to  reach 
eminence  of  the  kind  and  degree  that  would  warrant  the  trustees  to  select  him 
as  head  of  a  department  of  medicine,  surgery,  or  obstetrics  and  gynecology.  As 
a  result,  quite  apart  from  their  abilities,  the  newcomers  had  a  crowd  of  pupils 
and  voluntary  assistants,  eager  to  follow  new  leaders.  The  latter  were  for¬ 
tunately  chosen,  and  their  influence  upon  medical  and  surgical  research  and 
practice,  both  within  and  without  Baltimore,  is  too  well  known  to  need  elab¬ 
oration  here.  Since  the  tracing  of  the  effects  of  the  Johns  Hopkins  institutions 
upon  the  local  medical  profession  is  a  part  of  this  review,  it  may  not  be  out 
of  place  to  point  out  a  phase  that  has  not  received  the  appreciation  that  its  im¬ 
portance  warrants.  Perhaps  the  impression  of  the  most  fundamental  impor¬ 
tance  made  upon  the  band  of  Welch's  pupils  who  followed  the  clinical  branches 
in  the  hospital — and  they  were  chiefly  the  ones  who  were  best  equipped  to 
receive  the  new  gospel — was  gained  in  the  surgical  service  of  Halsted.  There 


16 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


under  this  master  in  surgery,  they  observed  the  methods  of  the  laboratory 
constantly  appealed  to  and  applied  in  a  manner  wholly  new  and  in  a  truly 
philosophical  spirit.  There  they  saw  the  aseptic  technique  carefully  built  up, 
the  healing  of  wounds  studied,  and  new  operations  developed,  all  under  exactly 
controlled  experiments. 

Osier’s  influence  was  both  deep  and  broad.  Excelling  in  knowledge  of  the 
natural  history  of  disease  and  of  the  fundamental  relation  between  pathology 
and  diagnosis,  qualities  that  the  local  contemporary  leaders  in  the  profession 
prided  themselves  upon,  he  was  in  addition  familiar  with  the  chemical,  micro¬ 
scopical,  and  bacteriological  methods  of  diagnosis  in  which  they  were  deficient. 
With  these  qualifications  and  his  great  gifts  of  mind  and  character,  Osier  at 
once  assumed  leadership  and  set  new  standards  of  diagnosis  and  of  hospital 
and  dispensary  organization.  His  critical  attitude  toward  the  value  of  many 
drugs  in  the  treatment  of  disease  was  largely  responsible  for  winning  the  battle 
for  expectant  treatment  and  a  fuller  realization  of  the  importance  of  vis  medi- 
catrix  naturae. 

Kelly’s  advent  fell  at  a  propitious  time  for  obstetrics  and  gynecology,  in 
which  both  teaching  and  consulting  practice  were  very  largely  in  the  hands  of 
relatively  old  men,  who,  however  great  had  been  their  services  in  the  past, 
unlike  the  general  surgeons,  were  incapable  of  taking  full  advantage  of  anti¬ 
septic  methods  to  extend  the  boundaries  of  their  fields.  Apt  in  acquiring  the 
new  technique  and  possessed  of  unusual  natural  and  acquired  surgical  gifts  and 
a  peculiar  combination  of  boldness  and  versatility  of  resource,  he  soon  made 
radical  advances  in  gynecology  and  set  new  standards  of  obstetrics  in  Baltimore. 

The  School  of  Nursing  in  the  Johns  Hopkins  Hospital  exerted  almost  im¬ 
mediately  a  beneficial  effect  upon  nursing  in  the  Baltimore  hospitals  and 
dispensaries. 

The  immediate  effects  upon  the  local  medical  schools  of  the  Johns  Hopkins 
Medical  School  upon  its  opening  in  1893  were  exerted  directly  in  improving 
methods  and  facilities  for  teaching  and  indirectly  in  taking  away  most  of  the 
local  medical  students  with  college  training.  From  this  time  on,  it  was  clear 
that  the  graduates  of  the  new  school  with  its  higher  standards,  exact  scientific 
methods,  and  more  ample  facilities  must  turn  out  a  new  type  of  physician 
who  would  in  time  be  the  leader  and  dominate  medical  thought  and  action,  and 
this  prophecy  was  fulfilled  in  a  remarkably  short  time.  The  transition  was  the 
easier  because  of  the  gradual  leavening  process  that  had  been  in  progress  since 
1880.  This  process  was  evolutionary  rather  than  revolutionary,  and,  owing  to 
the  good  spirit  of  the  leaders  and  mass  of  the  profession,  as  well  as  of  the 
teachers  in  the  new  and  in  the  old  schools,  the  metamorphosis  was  accom¬ 
plished,  on  the  whole,  with  remarkable  smoothness  and  lack  of  bitterness.  As 
a  result,  the  profession  held  together  without  serious  splits,  and  in  the  Medical 
and  Chirurgical  Faculty  and  other  societies  working  in  harmony,  it  was  able 
to  exert  a  salutary  influence  in  improving  medical  practice  and  in  securing 
remedial  legislation  and  improvement  in  administrative  measures  in  matters 
concerning  the  public  health.  The  final  result  has  been  that  in  public  con¬ 
fidence  and  influence,  the  medical  profession  of  Baltimore,  which  always  stood 
high,  has  outstripped  all  others. 

The  names  of  those  who  stand  out  after  the  lapse  of  time  as  real  leaders  and 
contributors  to  medicine  in  Baltimore  are :  Henry  Stevenson,  the  inoculator ; 


PHYSICAL  AND  SOCIOLOGICAL  DATA  CONCERNING  BALTIMORE  17 


Charles  Wiessenthal,  the  educated  physician,  patriot,  and  medical  reformer; 
James  Smith,  the  vaccinator;  Andrew  Wiessenthal  and  George  Buchanan,  the 
early  medical  teachers;  John  B.  Davidge,  author  and  student  and  the  father 
of  the  University  of  Maryland;  David  Meredith  Reese,  the  student  and  his¬ 
torian  of  yellow  fever;  Ashton  Alexander  and  Thomas  E.  Bond,  advisers  in 
public-health  administration;  Horatio  C.  Jameson,  surgeon  and  student  of 
public  health;  Pierre  Chatard,  the  great  obstetrician;  George  Frick,  the  eye 
surgeon;  Nathaniel  Potter,  the  medical  philosopher  and  experimenter;  Na¬ 
than  R.  Smith,  Gibson,  and  Halsted,  the  surgeons ;  and  Elisha  Bartlett,  William 
Power,  Thomas  H.  Buckler,  Charles  Frick,  William  T.  Howard,  Sr.,  William 
Osier,  and  William  D.  Booker,  students  of  the  natural  history  of  disease. 

HOSPITALS  AND  DISPENSARIES. 

Institutions  of  this  type  exert  both  direct  and  indirect  effects  upon  the  mor¬ 
bidity  and  mortality  of  a  community.  The  beneficial  influences  of  hospitals 
upon  morbidity  in  furnishing  asylum  for  the  isolation  of  persons  with  com¬ 
municable  diseases  occurring  in  the  general  population  may  be  largely  counter¬ 
balanced  in  improperly  constructed  and  managed  institutions  by  the  spread  of 
communicable  diseases  so  introduced  among  their  own  populations.  There  is 
ample  evidence  that  typhus,  typhoid,  and  puerperal  fevers,  erysipelas,  scarlet 
fever,  measles,  diphtheria,  dysentery,  and  small-pox  have  often  been  so  spread 
in  the  public  and  private  hospitals  in  Baltimore.  That  hospitals  have,  at  least 
within  the  last  100  years,  tended  to  lower  mortality  may  be  conceded.  On 
the  other  hand,  hospitals,  especially  those  widely  known,  with  men  on  their 
staffs  of  considerable  reputation  in  this  or  that  branch,  notably  in  surgery  and  its 
subdivisions,  attract  large  numbers  of  non-resident  sick — many  poor  operative 
risks  and  some  hopelessly  ill,  an  uncertain  proportion  of  whom  inevitably  die 
in  the  city.  Thus,  hospitals  of  this  class,  which  have  been  and  are  relatively 
numerous  in  Baltimore,  by  adding  to  the  number  of  deaths  of  non-residents, 
have  certainly  been  responsible  for  an  increase  in  the  gross  number  of  deaths 
chargeable  against  the  city.  Dispensaries,  besides  serving  as  centers  for  the  dis¬ 
pensation  of  treatment  to  the  poor,  have  long  been  recognized  as  valuable  aids 
to  public-health  administration,  because  in  them  often  the  earliest  cases  of 
certain  communicable  diseases  in  the  community  are  discovered. 

PUBLIC  HOSPITALS. 

The  public  hospitals  of  Baltimore  have  by  their  location  exerted  an  appar¬ 
ently  favorable,  though  really  fictitious,  influence  on  the  death-rate,  both  gen¬ 
eral  and  specific,  of  Baltimore,  since  the  deaths  occurring  in  all  of  them  at 
one  time  or  another  have  been  credited  to  the  places  in  which  the  institutions 
were  situated,  rather  than  to  the  place  from  which  the  sick  were  sent.  This 
was  particularly  true  of  the  infirmary  or  hospital  wards  in  connection  with 
the  almshouse,  and  the  hospitals  in  connection  with  the  quarantine  station,  all 
of  which  at  one  time  or  another  have  been  situated  beyond  the  limits  of  the 
city,  and  to  all  of  which  city  patients  with  acute  diseases  have  been  sent.  In 
the  earlier  period  of  the  city’s  history,  it  is  unlikely  that  the  bodies  of  individ¬ 
uals  dying  at  the  almshouse,  even  of  non-communicable  diseases,  were  brought 


18 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


to  the  city  and  buried  in  Potter’s  Field  or  other  cemeteries.  Since  the  tables 
of  mortality  were  compiled  from  the  reports  of  the  sextons  of  cemeteries,  until 
death  certificates  were  required  in  1875,  and  since,  even  after  this  time  in  some 
years,  the  large  number  of  deaths  at  Bayview  Asylum  and  Sydenham  Hospital 
were  excluded  from  the  list  of  city  deaths,  and  since  it  has  been  constant  prac¬ 
tice  to  exclude  from  this  list  all  deaths  at  the  Quarantine  Hospital,  these  omis¬ 
sions  are  of  considerable  importance.  The  almshouse  infirmaries  served  a  double 
function  in  affording  hospital  care  to  some  of  the  indigent  sick  in  the  general 
population,  as  well  as  to  the  sick  among  their  own  residents.  Since  the  latter  are 
recruited  in  general  from  those  of  middle  or  advanced  age  in  the  general  popu¬ 
lation  with  a  relatively  short  life  expectancy,  when  the  deaths  among  them  are 
omitted  from  the  city  bills  of  mortality,  it  amounted  to  withdrawing  from  the 
city  each  year  a  certain  number  of  poor  risks  and  to  subtracting  the  deaths 
among  them  from  the  total  deaths. 

The  first  public  hospital  was  opened  in  1776  or  1777  as  an  infirmary  in  con¬ 
nection  with  the  large  almshouse  of  Baltimore  City  and  County,  situated  just 
without  the  town,  near  the  present  Richmond  Market.  There  is  no  record  of 
the  number  of  beds,  but  the  wards  of  the  infirmary  were  certainly  open  to  the 
sick  poor  without  as  well  as  within  the  almshouse.  The  almshouse  and  its 
infirmary  were  transferred  to  new  quarters  without  the  city  limits  at  Calverton 
in  1823.  The  infirmary  continued  to  serve  as  a  hospital  for  the  city  poor,  and 
it  received  cases  of  acute  and  chronic  diseases.  There  was  also  an  obstetrical 
ward  and  a  ward  for  foundlings.  The  city  authorities  often  used  it  as  a  pest- 
house.  Severe  outbreaks  of  cholera  occurred  there  in  1832  and  in  1849.  A 
vivid  picture  of  the  risks  run  by  those  sentenced  to  this  hospital  is  given  in  the 
following  quotations  from  T.  H.  Buckler’s  (11)  description  published  in  1851  : 

“  A  single  case  of  erysipelas  brought  to  the  house  would  often  in  a  very  short  time, 
spread  the  infection  to  all  the  other  wards,  rendering  it  dangerous  to  perform  the  most 
simple  operation,  even  that  of  bleeding.  The  slightest  wound  was  sure  to  be  followed 
by  erysipelas,  phlebitis,  and  in  some  instances,  gangrene,  and  all  this  was  attributed  to 
hospital  atmosphere.  Was  it  the  air  of  the  wards  alone,  or  other  causes,  which  produced 
these  results?  The  establishment  affording  no  facilities  for  isolation,  it  was  not  unusual 
to  see  in  the  same  ward,  at  the  same  time,  cases  of  typhoid  fever,  erysipelas,  dysentery, 
and  typhus  or  ship  fever.  And  it  repeatedly  happened  that  patients  admitted  with  pneu¬ 
monia,  pleurisy,  or  some  other  acute  affection  were  seized,  before  their  convalescence 
was  perfectly  established  with  some  one  of  these  morbid  poisons,  which,  in  the  weak 
state  of  their  systems,  too  often  proved  fatal.  It  is  at  best  but  poor  humanity  to  send  a 
man  to  a  charity  hospital,  to  get  rid  of  one  affection,  and  at  the  same  time,  place  him 
under  circumstances  where  he  is  very  likely  to  contract  a  much  more  dangerous 
malady . In  1844,  and  again  in  1845,  when  the  house  was  under  the  care  of  Pro¬ 

fessor  Power,  of  the  University  of  Maryland,  the  poison  of  puerperal  fever  was  so  in¬ 
tense  that  death  was  sure  to  ensue  in  the  case  of  every  lying-in  woman,  the  attack  com¬ 
mencing  usually  in  from  4  to  12  hours  after  parturition.  In  each  of  these  years,  some 
8  or  10  cases  consecutively  proving  fatal,  this  ward  was  abandoned,  the  women  expecting 
confinement  were  sent  to  the  Washington  College  Hospital,  and  no  other  cases  of  the 
kind  were  admitted  for  a  period  of  6  months.  Every  summer  the  children  suffered  from 
cholera  infantum,  and  where  they  escaped  this  disease,  they  were  almost  sure  to  perish 
in  the  winter  with  pneumonia.  In  the  whole  history  of  the  establishment  there  is  no 
single  example  of  a  foundling  that  has  lived  to  the  age  of  3  years.” 

A  shift  was  made  to  a  new  and  commodious  plant  at  Bayview  in  1866,  the 
mixed  almshouse  and  hospital  features  being  preserved.  During  the  last  20 


PHYSICAL  AND  SOCIOLOGICAL  DATA  CONCERNING  BALTIMORE  19 


years  extensive  additions  and  improvements  have  been  made,  including  a  sepa¬ 
rate  general  hospital  for  general  diseases  of  about  150  beds  for  the  city  poor. 
There  was  established  also  a  separate  tuberculosis  hospital  for  advanced  cases. 
For  many  years  there  has  been  a  pavilion  to  accommodate  the  insane  among 
city  residents,  for  whom  the  State  insane  asylums  did  not  afford  room. 

In  1797,  the  legislature  authorized  the  erection  in  or  near  Baltimore  of  a 
hospital  for  indigent  sick  and  lunatics.  This  hospital,  variously  known  as  the 
Public,  City,  or  Maryland  Hospital,  was  located  without  the  city  limits  of  that 
time,  on  an  elevated  site,  now  occupied  by  the  J ohns  Hopkins  Hospital.  It  was 
opened  in  1800,  when  about  one-thirckcompleted,  with  130  beds.  It  was  leased 
in  1808  to  I)rs.  Colin  McKenzie  and  James  Smith  for  a  period  of  15  years, 
and  in  1814  the  lease  was  extended  on  condition  that  the  lessees  would  complete 
the  central  building,  a  lunatic  asylum,  and  an  additional  hospital  wing.  It  was 
to  this  hospital  that  yellow  fever  patients  were  sent  in  during  the  epidemics 
between  1800  and  1819.  In  1814,  234  sick  and  wounded  soldiers  were  re¬ 
ceived,  after  the  battle  around  Baltimore.  The  courts  began  to  commit  the 
insane  to  special  wards  of  this  hospital  in  1807.  Clinical  lectures  were  given  in 
the  hospital  in  1818  by  Professor  Nathaniel  Potter,  and  in  1822  by  Drs.  Colin 
McKenzie  and  George  Frick.  By  the  annexation  of  1816,  this  hospital  came 
within  the  limits  of  the  city. 

Between  1826  and  1834,  additional  buildings  were  completed,  the  administra¬ 
tion  of  the  hospital  passed  to  the  State,  and  admissions  were  limited  to  the  in¬ 
sane.  It  appears  that  for  some  years  before  the  latter  date  this  hospital  had 
admitted  sick  sailors  and  immigrants  with  certain  communicable  diseases.  This 
institution  was  finally  abandoned  as  an  insane  asylum  after  the  completion  of 
the  new  State  Hospital  for  the  Insane  at  Spring  Grove  in  1854,  and  the  prop¬ 
erty  was  soon  afterwards  purchased  by  Mr.  Johns  Hopkins,  and  later  became  the 
site  of  the  hospital  founded  by  him. 

The  account  of  the  quarantine  hospitals  will  be  given  in  connection  with  the 
quarantine  station. 

During  the  cholera  epidemic  of  1832,  the  health  department  conducted  three 
improvised  hospitals,  and  about  1835  it  opened  a  small-pox  hospital,  which,  in 
1837,  was  leased  to  the  Washington  Medical  University,  with  the  provision  that 
when  necessary  a  certain  number  of  small-pox  patients  would  be  received  at 
a  stipulated  per  diem  charge,  an  arrangement  held  to  until  the  opening  of  the 
marine  hospital  of  the  quarantine  station  in  1847. 

For  a  number  of  years  the  city  has  paid  a  small  per  diem  charge  to  a  num¬ 
ber  of  private  hospitals  for  the  care  of  indigent  sick,  for  whom  no  room  was 
available  in  the  almshouse  infirmary. 

In  1909,  Sydenham  Hospital,  with  accommodations  for  40  cases  of  diph¬ 
theria,  scarlet  fever,  measles,  and  chicken-pox,  was  opened.  In  1914  it  was 
expanded  to  accommodate  60  patients. 

PUBLIC  DISPENSARIES. 

The  city  has  supported  several  general  dispensaries  for  the  treatment  of  the 
poor.  The  most  important  of  these  and  the  dates  of  their  foundation  are :  The 
Baltimore  General,  1808;  the  Eastern,  1818;  the  Western,  1847;  and  the 
Southern,  1847. 


20 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


PRIVATE  HOSPITALS. 

The  hospitals  placed  under  this  heading  were  built  and  conducted  not  by 
the  city  authorities,  but  by  chartered  corporations,  and  their  chief  and  in  some 
instances  sole  source  of  support  has  been  derived  from  gifts  and  endowments 
and  fees  of  patients.  Many  have  succeeded  in  securing  appropriations  from  the 
State.  Most  of  them  have  received  small  per  diem  payments  for  indigent  pa¬ 
tients,  for  whom  room  was  not  available  in  the  city-owned  hospitals,  and  at 
times,  for  some  hospitals  especially,  this  has  been  an  important  item  until  re¬ 
cently.  Nearly  all  of  these  hospitals  throughout  their  history  have  posed  as 
charitable  institutions,  created  and  maintained  primarily  for  the  care  of  the 
poor,  but  in  most  instances  even  cursory  investigation  shows  that  this  is  not 
true.  These  institutions  readily  fall  into  distinct  categories  : 

(1)  There  are  those  institutions  started  in  connection  with  medical  schools, 
the  primary  aim  in  the  foundation  and  conduct  of  which  was  clinical  material 
for  teaching  students,  a  theater  for  the  professors,  and  hospital  accommodations, 
particularly  private  rooms,  for  the  patients  of  the  latter.  From  the  start  they 
were  important  to  the  medical-professor  business.  The  first  hospital  of  this  class, 
the  Baltimore  Infirmary,  was  founded  in  connection  with  the  University  of 
Maryland  Medical  School  and  opened  in  1823  with  4  public  or  free  wards. 
There  was  a  considerable  enlargement  in  1850  with  private  rooms.  Later  ex¬ 
pansions  have  greatly  increased  the  total  accommodations  for  both  free  and 
pay  patients.  This  general  hospital  has  maintained  an  obstetrical  service  for 
many  years,  housed  in  a  separate  building  since  about  1885,  and  at  one  time 
had  a  ward  for  acute  contagious  diseases,  where  patients  from  steamship  com¬ 
panies  were  received  on  contract.  The  second  was  that  of  Washington  Medical 
College,  established  in  1838  and  closed  with  the  failure  of  the  school  in  1851. 
The  small  so-called  City  Hospital  was  developed  by  the  College  of  Physicians 
and  Surgeons  after  1878,  and  about  1890  it  was  taken  in  charge  by  a  Catholic 
sisterhood,  which  has  been  largely  responsible  for  securing  funds  and  for 
elevating  it  into  a  large  general  hospital.  However,  the  private  rooms  for  pay¬ 
ing  patients  of  this  hospital  form  a  very  large  part.  This  hospital,  with  its  large 
dispensary  service,  was  the  main  source  of  clinical  material  for  the  college  whose 
professors  formed  the  medical  and  surgical  staff.  The  Maternity,  a  small  lying- 
in  hospital,  the  first  separate  hospital  of  its  kind  in  Maryland,  established  in 
1878,  was  conducted  under  the  control  of  the  same  faculty.  The  Maryland  Gen¬ 
eral  Hospital,  a  small  hospital  with  a  few  private  rooms  and  public  wards, 
maintaining  a  precarious  existence,  was  annexed  by  the  Baltimore  Medical 
College  in  1881,  and  during  the  meteoric  career  of  this  college  expanded  rapidly, 
and  with  the  expiration  of  the  latter  in  1914,  the  hospital  absorbed  the  col¬ 
lege  buildings.  Here  a  maternity  ward  and  a  large  dispensary  service  were 
maintained  so  long  as  clinical  material  for  teaching  was  needed.  The  religious 
sect  chiefly  appealed  to  for  support  is  the  Methodist.  The  Woman’s  Medical 
College  also  conducted  a  small  hospital.  A  hospital  of  considerable  size  was 
supported  for  many  years  in  connection  with  the  Homeopathic  Medical  College. 

(2)  Hospitals  built  and  maintained  by  private  associations,  usually  more  or 
less  identified  with  religious  sects,  many  of  them  receiving  larger  or  smaller  ap¬ 
propriations  from  the  State  either  for  buildings  or  maintenance  or  both,  form  a 
second  class.  The  earliest  of  these  was  the  Union  Protestant  Infirmary,  a  small 


PHYSICAL  AND  SOCIOLOGICAL  DATA  CONCERNING  BALTIMORE  21 


hospital  opened  in  1854,  with  private  rooms  and  open  wards,  for  charity  and 
part-pay  patients.  Since  1895  it  has  undergone  considerable  expansion  and 
has  become  very  largely  a  surgical  hospital.  The  old  college  and  hospital  of  the 
defunct  Washington  Medical  University  were  organized  into  a  church  home 
and  infirmary  in  1854,  under  the  auspices  of  the  Protestant-Episcopal  Church, 
and  in  recent  years,  with  considerable  additions,  it  has  become  an  important 
hospital,  with  the  traditional  private  rooms  for  pay  patients,  chiefly  surgical. 
St.  Joseph's  Hospital,  founded  in  1864,  and  St.  Agnes  Hospital,  the  latter  until 
recently  without  the  city  limits  and  organized  in  1878,  both  supported  and 
managed  by  sisterhoods  of  the  Catholic  Church,  have  grown  from  small  be¬ 
ginnings  into  large  and  relatively  well-equipped  hospitals  receiving  both  free 
and  pay  patients.  St.  Joseph's  Hospital  conducts  a  large  free  dispensary.  The 
Franklin  Square  Hospital  and  the  South  Baltimore  Hospital  are  small  general 
hospitals  with  open  wards  and  private  rooms.  There  are  several  special  hos¬ 
pitals  for  eye  and  ear  diseases,  the  oldest  and  most  prominent  being  the  Presby¬ 
terian  Eye  and  Ear  Hospital,  founded  in  1871,  with  20  free  beds  and  private 
rooms.  As  its  name  suggests,  its  special  support  comes  from  the  Presby¬ 
terian  Church,  the  religious  sect  of  its  talented  first  surgeon-in-chief.  The 
Woman's  Hospital,  founded  in  1882,  with  an  appropriation  from  the  State, 
for  the  treatment  of  the  special  diseases  “  of  the  poor  women  of  Maryland," 
modeled  on  the  famous  hospital  of  the  same  name  in  New  York,  with  a  staff  of 
two  chief  and  four  assistant  gynecologists,  and  governed  by  a  board  of  trustees 
and  a  board  of  lady  managers,  opened  with  only  free  beds.  A  few  years  later, 
against  the  protests  of  one  of  the  chief  gynecologists,  rooms  for  private  pay 
patients  wnre  added.  Since  1908,  this  hospital  has  expanded  into  a  large  hos¬ 
pital  composed  almost  altogether  of  private  rooms  for  pay  patients,  receiving 
cases  of  all  affections  among  women  usually  admitted  to  a  general  hospital; 
and  with  its  heterogeneous  staff,  it  has  lost  completely  its  original  features  of 
a  free  hospital  for  the  treatment  of  women  of  Maryland,  suffering  with  diseases 
peculiar  to  their  sex.  Though  the  plant  has  been  greatly  enlarged,  scarcely  any 
more  patients  of  the  character  for  which  it  was  founded  are  now  accommodated 
than  were  a  few  years  after  it  was  opened. 

(3)  There  are  also  hospitals  built  and  maintained  by  endowments  from  pri¬ 
vate  individuals,  founded  and  conducted  to  relieve  the  indigent  sick  and  those 
who  can  afford  to  pay,  with  charges  to  the  latter,  either  in  public  or  private 
wards,  graduated  according  to  their  means.  The  Robert  Garrett  Hospital  for 
Children  was  founded  in  1888.  This  hospital,  with  modern  equipment  and  a 
large  free  dispensary  service,  accommodates  30  children  with  medical  and  sur¬ 
gical  diseases.  The  large  and  constantly  expanding  Johns  Hopkins  Hospital, 
a  model  of  its  kind,  with  accommodations  for  both  pay  and  free  patients,  and 
well-organized  general  and  special  dispensary  services,  was  opened  in  1889. 

CHARITIES. 

Baltimoreans  have  always  been  notable  for  charity,  and  here,  as  elsewhere, 
organized  charity  began  with  personal  relationships,  religious  organizations, 
and  race  groups,  and  developed  later  into  special  and  general  relief  systems. 
The  public  treasury  was  successfully  appealed  to  first  for  special  needs  and  later 


22  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

for  systematic  help.  It  is  beyond  the  scope  of  this  work  to  give  more  than  the 
barest  outline  of  charities  and  charitable  institutions  as  they  have  had  a  direct 
bearing  upon  public  health  and  mortality. 

While  in  the  long  run  it  may  be  true  that  in  old  settled  countries,  where  the 
laws  of  the  relation  of  population,  including  health  and  mortality,  are  so 
closely  bound  up  with  subsistence  derivable  from  home  lands  or  purchasable 
abroad  with  money  gained  in  trade,  manufacture,  and  other  services,  the  pres¬ 
ervation  of  the  lives  of  the  very  poor  by  private  and  public  charity  is  useless 
and  even  immoral;  still,  in  a  new  country  and  particularly  in  a  town  and  city 
so  situated  as  Baltimore,  where,  in  general,  the  restrictions  on  population 
growth  by  propagation  have  been  relatively  slight,  it  is  probably  correct  to  as¬ 
sume  that,  on  the  whole,  benevolence  administered  to  the  needy  and  unfor¬ 
tunate,  either  in  large  groups  under  special  conditions  or  to  smaller  groups 
and  to  individuals  routinely,  by  tiding  them  over  difficulties  in  times  of  special 
stress,  has  so  far  tended  to  increase  of  population  and  to  lighten  or  at  least  to 
deflect  the  force  of  mortalitv. 

t/ 

The  English  system  of  tax  levies  by  law  officers  for  the  support  of  the  poor 
was  applied  in  early  Baltimore,  as  well  as  in  the  rest  of  the  colony.  In  1773,  to 
do  away  with  the  abuses  of  the  system,  a  loan  of  £4,000  was  made  by  the  State 
to  Baltimore  Town  and  County  for  the  building  of  an  almshouse,  to  be  ad¬ 
ministered  by  a  corporate  body,  the  Trustees  of  the  Poor,  and  in  connection 
with  it,  there  was  a  workhouse  for  the  reception  and  lodging  of  vagrants  or 
other  offenders  committed.  This  almshouse,  erected  first  on  a  large  lot  of 
land  near  the  present  Richmond  Market,  moved  in  1822  to  Calverton,  and  in 
1866  to  Bayview,  has  remained  a  permanent  feature  of  Baltimore  municipal 
charity,  and  during  its  existence  has  carried  a  large  proportion  of  the  poor  and 
destitute,  for  whom  it  has  always  maintained  an  infirmary,  into  which  have  also 
been  received  indigent  sick  directly  from  the  general  population.  For  many 
years,  the  Trustees  of  the  Poor  supported  a  few  pensioners  without  the  alms¬ 
house. 

Since  early  days  there  have  existed  a  large  number  of  homes  for  old  people 
and  orphan  asylums  for  children  of  each  sex,  often  with  associated  schools. 
They  are  usually  identified  with  some  religious  sect  or  racial  organization,  and 
several  have  accumulated  handsome  endowments. 

About  1800,  societies,  based  on  racial  ties,  were  first  organized  to  help,  advise, 
and  protect  individuals  of  certain  races  and  their  descendants.  The  most  im¬ 
portant  were  the  German  (1784),  the  Hibernian  and  the  St.  George  (1803),  St. 
Andrews  (1806),  and  the  Hebrew  Benevolent  Society  (1834).  Out  of  all  these, 
various  benevolent  activities  have  grown. 

The  great  increase  of  immigrants  during  the  fourth  and  fifth  decades  of  the 
nineteenth  century  included  many  who  were  destitute,  and  by  1849,  poverty 
and  even  pauperism  having  become  a  very  serious  question,  the  Association  for 
the  Improvement  of  the  Poor  was  organized  on  a  broad  and  representative 
basis.  This  was  succeeded  by  the  Charity  Organization  Society  in  1881  and  the 
Federated  Charities  in  1908.  In  the  meantime,  during  the  Civil  War,  the  calls 
upon  privately  supported  charities  had  become  so  overwhelming  that  a  num¬ 
ber  of  these  agencies  found  it  necessary  to  obtain  aid  from  the  city  government. 
In  1870,  7  institutions  received  $22,000  city  aid,  and  by  1896,  51  were  dividing 
$277,275. 


PHYSICAL  AND  SOCIOLOGICAL  DATA  CONCERNING  BALTIMORE 


23 


The  St.  Vincent  de  Paul  Society,  growing  out  of  parisli  conferences  in  1865, 
incorporated  in  1869,  and  since  widely  extended,  is  the  representative  Catholic 
society  for  general  relief.  It  is  closely  affiliated  with  the  large  number  of  or¬ 
phanages,  homes,  schools,  and  other  benevolent  institutions  maintained  by 
members  of  the  Catholic  church.  Two  of  these,  in  which  large  numbers  of 
children  have  been  received,  are  the  St.  Vincent’s  Orphan  Asylum  and  St. 
Elizabeth’s  Home  for  Colored  Children,  the  latter  established  in  1879. 

The  most  conspicuous  endowments  for  public  aid  have  been  the  Henry  Wat¬ 
son  Children’s  Aid  Society,  $100,000  (1880),  and  the  Thomas  Wilson  Sana 
torium  for  Sick  Children,  $500,000  (1880).  In  close  connection  with  the  latter, 
operates  the  Babies’  Milk  Fund  (1904),  with  its  large  number  of  welfare  sta¬ 
tions  and  nurses  for  babies.  These  two  institutions  have  doubtless  exercised  a 
large  influence  in  late  years  in  decreasing  the  mortality  among  the  young. 

During  the  last  20  years,  charity  and  benevolent  societies  have  multiplied, 
expanded,  and  coordinated,  and  have  covered  the  field  of  nursing,  tuberculosis, 
playgrounds,  athletics,  and  the  like.  Many  local  and  city-wide  associations  for 
general  betterment  of  living  conditions  have  been  formed.  Among  the  most  ac¬ 
tive  of  the  latter  is  the  Woman’s  Civic  League,  which  has  exerted  an  important 
influence  on  measures  to  promote  the  public  health,  especially  in  connection 
with  improving  the  milk-supply.  The  union  of  14  of  the  more  important  benevo¬ 
lent  organizations  in  the  Alliance  of  Charitable  Agencies  in  1914  has  re¬ 
sulted  in  expansion  and  better  coordination  of  city-wide  benevolence.  The 
Hebrew  Benevolent  Association,  upon  which  unusual  demands  had  been  made 
on  account  of  the  large  influx  of  oppressed  Jews,  particularly  from  Bussian 
Poland,  during  the  past  30  years,  had  already  consolidated  and  expanded  their 
work  in  a  manner  somewhat  similar. 

Fraternal  societies  of  various  types  have  always  been  numerous  and  strong 
in  Baltimore. 

Speaking  broadly,  the  private  and  semi-public  benevolent  associations  and 
their  correlated  institutions  have  become  grouped  about  three  great  religious 
divisions,  Protestant,  Catholic,  and  Jewish,  among  which,  however,  the  rivalry 
is  friendly  and  to  a  remarkable  degree  cooperative  and  free  from  prejudice.  The 
problems  of  the  Catholics  have  been  especially  complicated,  because  of  the  dif¬ 
ferences  of  race-stock  and  language,  which  tend  to  cause  and  to  perpetuate  social 
isolation  of  large  groups,  such  as,  Poles,  Italians,  Bohemians,  Lithuanians,  and 
some  others,  who  are  still  largely  in  the  first  and  second  generations,  and  among 
whom  benevolent  associations  must  naturally  incline  toward  race-stock  group¬ 
ings.  These  problems  obtain  to  but  a  small  degree  among  Protestants. 

The  great  nationality  or  race-stock  benevolent  societies,  such  as  the  Hiber¬ 
nian,  the  German,  the  St.  Andrew,  and  St.  George  Societies,  agents  of  such 
great  importance  in  earlier  days  when  organized  to  relieve  the  imperative  neces¬ 
sities  of  recent  immigrants,  have,  with  the  decrease  in  the  latter  and  the  general 
improvement  in  conditions,  naturally  diminished  in  importance  as  relief 
organizations. 

There  are  no  conspicuously  large  benevolent  associations  conducted  and  sup¬ 
ported  by  negroes  alone,  though  they  have  their  share  of  fraternal  orders  and 
benevolent  activities,  especially  in  connection  with  their  churches. 

Accident,  sick,  and  burial  insurance  in  both  local  and  foreign  companies  is 
very  prevalent  among  the  whole  population  of  Baltimore. 


24 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


In  review  it  may  be  said  that,  at  different  times,  especially  during  and  after 
wars  and  very  large  immigrations,  there  has  been  acute  suffering  from  poverty 
which  has  been  met  in  part  by  general  philanthropy,  by  special  organizations, 
and  by  contributions  from  the  public  treasury  in  a  degree  sufficient  in  the 
main  to  prevent  starvation  and  any  large  actual  loss  by  death ;  that  benevolent 
associations,  special  and  general,  have  protected  the  unfortunate,  usually  with¬ 
out  nursing  and  increasing  pauperism ;  and  that  during  its  whole  history  pro¬ 
vision  for  the  relief  of  want  has  been  made  from  the  public  treasury,  and  the 
tendency  during  the  last  50  years  has  been  to  call  on  the  latter  in  increasing 
proportions  and  to  consolidate  and  to  coordinate  the  various  private  and  semi¬ 
public  benevolent  agencies. 

SCHOOLS. 

The  public  school  system  was  established  in  1826,  but  before  and  since  this 
date  there  have  been  a  number  of  private  schools.  On  account  of  the  large  pro¬ 
portion  of  Eoman  Catholics  in  the  population,  the  parochial  schools,  attended 
by  a  considerable  moiety  of  children  of  Catholic  families,  are  of  more  than 
usual  importance.  So  far  as  the  buildings  for  this  purpose  are  concerned,  there 
is  no  reason  to  suppose  that  those  of  the  parochial  schools  differ  much  from 
those  supported  by  the  public  treasury.  The  public  schools  are  divided  into 
kindergarten,  grammar,  high,  and  technical  schools.  They  are  conducted  under 
a  board  of  school  commissioners.  There  are  separate  schools  for  whites  and 
negroes. 

In  1850,  according  to  Wynne  (12),  there  were  25  schools,  11  male  and  14  fe¬ 
male,  with  2  female  and  1  male  high  schools.  In  1848,  the  number  of  pupils 
(all  white)  was  6,693,  or  about  260  pupils  to  a  school.  Wynne  described  the 
schools  of  this  day  as  filthy  dirty,  crowded,  and  ill-ventilated.  At  that  date  the 
Brothers  of  the  Christian  Schools,  the  Brotherhood  of  St.  Patrick,  and  Mc- 
Kim’s  Free  School  (endowed)  accommodated  some  2,000  additional  pupils. 
During  the  days  of  the  clipper  ship,  the  school  authorities  conducted  a  nautical 
school,  with  a  ship,  for  the  training  of  boys  for  the  sea. 

During  the  next  60  years  there  was  some  improvement  in  the  physical  condi¬ 
tions  of  the  school-buildings.  In  his  report  for  1908  to  the  Commissioner  of 
Health,  Dr.  H.  Warren  Buckler,  as  medical  inspector  in  charge  of  a  group  of 
20  schools,  which  he  regarded  as  typical,  classed  them  as  follows  in  regard  to 
design,  structure,  cleanliness,  and  ventilation :  First  class  in  every  respect,  2 ; 
average,  justifying  neither  criticism  nor  praise,  10 ;  modem  well-designed  build¬ 
ings,  but  unclean  and  offensive  on  account  of  the  personal  habits  and  lack  of 
cleanliness  of  the  pupils,  4 ;  totally  unfit  for  educational  purposes,  4.  In  schools 
of  the  latter  class  the  school-rooms  were  too  dark  for  the  pupils  to  see  the  black¬ 
board,  the  desks  were  misfits  (all  of  the  same  size  and  non-adjustable),  the 
buildings  were  dirty  and  without  proper  toilets.  The  overcrowding  was  con¬ 
spicuous;  in  a  room  picked  at  random,  with  a  floor  space  of  18.5  by  12.5  feet 
and  2  windows,  there  were  40  pupils.  One  of  these  schools,  used  for  negroes, 
beggared  description.  The  new  schools  Buckler  described  as  models  for  their 
purpose.  Thus,  according  to  his  report,  it  would  seem  that  of  the  public-school 
buildings  20  per  cent  were  entirely  unfit,  50  per  cent  were  passable,  and  30 
per  cent  were  to  be  condemned.  It  is  probable  that  these  were  typical  samples 


PHYSICAL  AND  SOCIOLOGICAL  DATA  CONCERNING  BALTIMORE  25 


of  the  whole  number  of  public  schools  of  the  city.  Few  are  situated  on  or  near 
small  parks.  A  few  of  the  schools  have  large  yards,  but  for  the  most  part  the 
playground  space  is  seriously  restricted.  Largely  through  the  initiation  of 
Dr.  Buckler,  within  the  last  few  years  “  open-air  ”  schools  for  delicate  children 
have  been  established  in  connection  with  several  schools. 

From  the  reports  of  the  different  medical  inspectors,  the  same  conditions  as 
to  structure  and  overcrowding  obtain  in  the  parochial  schools. 

There  are  a  large  number  of  private  schools,  both  elementary  and  preparatory 
for  college,  for  both  boys  and  girls.  The  general  hygienic  conditions  of  these 
are  good,  and  some  are  models.  They  are  attended  by  a  larger  proportion  of 
children  than  is  usual  in  an  American  city. 

DWELLINGS. 

The  earlier  dwellings  of  Baltimore  Town  were  of  wood ;  the  first  brick  house 
was  built  in  1740.  It  was  not  until  after  the  rapid  growth  of  the  town  after 
1780,  in  an  area  surrounded  by  natural  obstructions  to  expansion  and  under 
conditions  demanding  warehouses  and  residences  near  the  water-front,  that 
the  construction  of  brick  dwellings  in  closely  built  blocks  became  the  custom. 
Wood  was  abandoned  as  a  building  material  because  of  danger  from  fire,  and 
brick  was  adopted  on  account  of  the  great  abundance  of  excellent  clay  near  at 
hand.  Stone,  plentiful  in  nearby  quarries,  was  often  used  in  foundations  and  for 
public  buildings,  but  was  never  a  serious  competitor  of  brick  in  dwellings  and 
warehouses.  *  jj  W] 

The  early  streets  being  comparatively  wide,  the  rectangular  squares  into 
which  the  town  was  laid  off  afforded  ample  space  for  the  erection  of  houses  of 
two  or  three  stories  in  height  in  compact  blocks  with  sufficient  provision  for  light 
and  air,  front  and  back.  The  squares  are  usually  cut  by  one  or  several,  usually 
two,  alleys  varying  from  3  to  10  or  even  more  feet  in  width,  which  give  con¬ 
venient  access  to  the  rears  of  the  houses  fronting  the  streets  on  the  four  sides 
of  the  squares.  The  end  houses  of  a  block,  with  the  street  or  alley  alongside, 
may  have  light  on  three  sides.  Since  the  squares  measure  about  300  feet  on  each 
of  their  four  sides,  and  the  houses  commonly  abut  the  paving  line,  there  is 
ample  room  for  a  comparatively  deep  yard  behind  each  house.  The  lots  carry 
ownership  to  the  center  of  the  alley  alongside  or  in  the  rear,  the  alleys  being  pri¬ 
vate  property  dedicated  to  the  convenient  use  of  the  occupants  of  abutting 
houses.  The  streets  vary  from  30  to  80  or  more  feet  in  width  from  house  to 
house.  Since  the  stage  and  wagon  roads  from  north,  south,  east,  and  west,  led  to 
the  water-front  and  were  necessarily  broad  to  accommodate  the  heavy  traffic 
wagons  plying  in  and  out  of  town,  with  the  growth  of  the  town  along  them, 
they  served  as  wide  avenues  radiatiug  from  the  lower  city  like  the  ribs  of  a 
fan,  sufficiently  distant  from  each  other,  however,  not  to  interfere  seriously 
with  the  regular  arrangement  of  streets  running  north  and  south  and  east  and 
west. 

The  dwellings  of  the  typical  city  square  of  the  better  sort  abut  the  foot-pave¬ 
ment  and  are  placed  often  in  unbroken  rows,  for  the  whole  length  of  opposite 
sides  of  a  street.  In  this  case  the  block  is  bisected  by  a  single  10  to  20  foot 
alley,  directly  in  the  rear  of  each  row  of  houses.  The  four  houses  at  the  corners 


26 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


of  the  square  have  light  and  air  on  three  sides  and  all  the  rest  on  two  sides.  The 
whole  center  of  the  square  is  open,  except  for  the  board  fences  which  separate  the 
yards  in  the  rear  of  each  house.  In  other  cases,  blocks  of  houses,  some  with 
less  deep  yards,  will  face  three  or  even  four  sides  of  a  square,  which  in  this  case 
will  be  traversed  completely  or  incompletely  by  a  second  or  even  a  third  alley  at 
right  angles  to  the  first.  In  this  case,  several  more  houses,  placed  necessarily 
alongside  of  alleys,  will  have  three  free  sides.  Each  yard  opens  upon  its  border¬ 
ing  alley  by  a  gate.  Only  occasionally  in  the  closely  built  up  sections  of  the 
city  are  any  of  the  houses  completely  detached,  but  not  infrequently  in  the 
richer  districts  there  will  be  one  or  more  side-yards  where  owners  have  double 
lots,  or  front  yards  when  the  houses  are  set  back  from  the  street.  Since  a  lot  may 
be  at  least  150  feet  deep,  even  large,  deep  houses  may  be  separated  by  at  least 
100  feet  from  rear  to  rear  in  a  block  with  a  single  bisecting  alley.  In  houses  so 
situated,  the  amount  of  light  and  air  available  for  each  house  depends  entirely 
upon  its  design  and  the  width  of  the  lot. 

From  these  optimum  conditions,  there  is  every  variation  to  closely  built 
squares  with  nearly  every  available  foot  occupied  by  buildings,  the  mass  of 
which  are  used  for  human  habitation.  In  the  first  place,  in  the  best  squares 
there  are  often  stables  and  coach-houses,  or  in  recent  times  garages,  at  the 
rear  of  some  of  the  lots.  The  latter,  in  older  parts  of  the  city,  often  were  also 
the  seat  of  large  or  small  houses  or  “  quarters  ”  for  domestic  servants — negro 
slaves  in  former  generations.  In  the  poor  districts  of  the  city,  especially  in  the 
south  and  southeastern  sections  near  Jones  Falls  and  the  harbor  and  the  basin, 
but  abundantly  found  as  foci  in  nearly  all  parts,  there  are  numerous  squares 
almost  solidly  built.  In  general,  this  has  occurred  in  one  or  both  of  two  ways : 
(1)  By  building  a  single  or  double  row  of  houses  along  the  intersecting  alley  or 
alleys  or  houses  about  closed  courts  within  the  square;  (2)  by  additions  on 
the  rear  of  the  original  houses.  Many  such  built-up  alleys,  8  or  10  feet  wide, 
extending  through  a  number  of  squares  and  later  accepted  by  the  city,  have  been 
dignified  by  the  name  of  streets.  These  alley  and  court  dwellings  have  existed  in 
the  oldest  sections  of  the  city  from  at  least  the  latter  part  of  the  eighteenth 
century,  and  these  types  of  intra  block  building  have  so  extended  that  in  the 
lower  southern,  southwestern,  and  in  much  of  the  western  districts  they  are 
characteristic  features.  It  is  not  unlikely  that  they  are  inhabited  by  as  much 
as  one-eighth  of  the  total  population.  The  crowding  of  squares  by  the  addi¬ 
tions  to  the  rear  of  dwellings  facing  streets  is  of  more  recent  origin,  but  in 
many  parts  of  the  city,  particularly  in  the  southeastern  segment,  extending 
on  both  sides  of  Jones  Falls  down  to  and  including  Fell’s  Point,  this  condition 
has  existed  for  many  years.  As  a  result  of  this  type  of  building  activity  in 
many  squares,  at  least  four-fifths  of  the  surface  is  covered  with  rambling  and 
interlocking  buildings,  attached  to  the  rear  of  old  residences ;  all,  except  when 
the  front  lower  rooms  of  the  latter  are  transformed  into  shops,  are  used  as 
dwellings. 

In  the  older  sections  of  the  city  near  the  water,  especially  at  Fell’s  Point, 
there  remain  dwellings  typical  of  the  early  city.  These  range  from  single¬ 
room  houses  and  two-room  1  or  2  story  houses  to  mansions  of  10  or  more  rooms. 
The  single  room,  two,  three,  and  four-room  houses  were  built  on  broad  as  well 
as  on  narrow  streets  and  on  alleys  and  courts.  The  early  small  houses  had  com- 


PHYSICAL  AND  SOCIOLOGICAL  DATA  CONCERNING  BALTIMORE  27 


paratively  small  windows,  but  they  were  well  built,  and  as  houses  or  dwellings, 
apart  from  lack  of  light  and  air  when  closely  grouped  in  alleys  and  courts, 
were  fit.  It  was  the  six  or  nine  room  house,  with  three  rooms  to  the  floor,  that 
was  so  often  especially  ill-suited  in  design  for  health.  In  many  of  these  houses 
the  entry  is  direct  into  the  front  room,  which  opens  into  a  center  or  hall  room 
without  windows.  The  back  room  is  either  dining-room,  with  a  single  window 
and  a  narrow  kitchen  behind,  or  combination  dining-room  and  kitchen.  From 
the  center  room  run  the  stairs,  and  on  the  two  upper  floors  there  is  often  a 
central  room  without  windows,  but  in  some  houses  of  this  class  there  is  ventila¬ 
tion  of  these  rooms  by  windows  on  shafts  or  by  skylights.  It  is  possible  that 
these  dark  rooms  were  not  used  for  sleeping-rooms,  but  as  hallways  and  as 
closets,  by  the  first  occupants.  Certain  it  is,  however,  that  when  these  houses 
passed  into  the  hands  of  poorer  people,  especially  recent  immigrants,  the  dark 
rooms  came  to  be  used  as  living  and  sleeping  quarters.  It  was  against  this  type 
of  house  especially  that  the  ordinance  of  1886  was  intended  to  apply.  It  is 
likely  that,  by  this  time,  houses  of  this  type  had  long  since  ceased  to  be  built. 
The  common  device  used  in  lighting  the  middle  room  of  a  house  three  or  more 
rooms  deep  is  to  have  a  space  for  a  rear  window  in  the  middle  room,  by  nar¬ 
rowing  the  back  of  the  building,  the  rooms  in  the  latter  in  turn  being  lighted  by 
side,  or,  in  the  case  of  the  last  room,  by  end  windows.  The  lower  hall,  now  al¬ 
most  invariably  the  entrance,  receives  light  from  a  window  light  in  the  front 
door,  and  the  upper  halls  from  a  broad  transom  in  the  roof.  In  this  way,  among 
others,  fairly  wTell  lighted  and  ventilated  houses  are  constructed  in  close  blocks. 
In  many  houses  there  is  no  or  only  one  room  over  the  back  building,  on  floors 
above  the  first.  The  larger  houses  of  the  richer  classes,  varying  greatly  in  de¬ 
sign,  are  characterized  by  comparatively  large  rooms  with  very  high  ceilings, 
but  in  many  one  or  more  of  the  rooms  on  each  floor  are  lacking  in  light.  In 
them,  however,  attic  rooms,  often  used  as  bedrooms  for  servants,  were  often 
dark  or  lighted  only  by  skylights.  In  many  of  the  smaller  houses  built  after 
the  ordinances  of  1886  and  1908,  rooms  on  the  second  and  third  floors,  used  as 
sleeping-rooms,  are  lighted  only  by  immovable  skylights  and  are  thus  defective 
in  ventilation. 

The  houses  for  the  most  part  have  cellars  for  storage  and  for  heating-plants 
under  the  main  structure.  In  many  parts  of  the  city,  especially  upon  made 
ground  and  in  the  lower  sections  and  elsewhere,  on  account  of  the  numerous 
springs,  much  difficulty  has  been  experienced  in  keeping  cellars  dry.  On  this 
account  the  early  ordinances  prescribed  methods  of  construction  intended  to 
prevent  access  of  water  to  cellars,  and  automatic  drainers  have  been  used  to 
dispose  of  water  entering  cellars  by  seepage.  From  early  times,  in  both  small 
and  large  houses,  in  higher  parts  of  the  city  and  especially  on  hillsides,  half 
cellars  or  basements  with  half  or  less  than  half  their  height  below  the  surface 
of  the  ground  and  lighted  by  windows,  have  been  used  not  only  for  basement 
kitchens  and  laundries,  but  for  dining-rooms  and,  among  the  poorer  people,  as 
sleeping-quarters.  In  the  older,  larger  houses,  occupied  by  people  who  can 
afford  domestics,  the  basement  kitchen  is  the  rule.  These  are  usually  well  lighted 
for  their  purpose  by  ample  windows. 

The  typical  block  dwelling  of  the  last  75  or  50  years  is  from  14  to  18  feet 
front  by  30  to  35  feet  in  depth,  and  of  2  to  4  stories.  The  cellar  or  basement, 

3 


28  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

lighted  by  windows  in  front  and  behind,  and  in  end  houses  on  one  side,  has  a 
furnace-room  with  storage  space  for  fuel,  a  kitchen  at  the  rear,  and  sometimes 
a  laundry.  On  the  first  floor  is  the  narrow  entrance  hall,  approached  from  the 
street  by  stone  steps  and  lighted  by  a  large  window-light  in  the  front  door. 
Opening  on  the  hall  is  the  comfortable  front  parlor,  with  its  one  large  or  two 
smaller  windows  looking  on  the  street.  Behind  this  is  the  dining-room,  entered 
from  the  hall  or  parlor  or  from  both.  This  room  is  poorly  lighted  by  side  win¬ 
dows,  if  the  kitchen,  as  is  sometimes  the  case,  is  on  the  first  floor,  or  by  one  or 
more  rear  windows,  if  a  first-floor  kitchen  behind  the  dining-room  is  narrower 
than  the  latter.  If  the  kitchen  is  in  the  basement,  the  dining-room  will,  in  the 
absence  of  a  back  building,  be  well  lighted.  A  center  room,  poorly  lighted  from 
the  dining-room,  or  from  a  narrow  area  window,  is  not  uncommon.  The  stairs 
lead  from  the  entrance  hall  to  the  second  floor,  with  its  front  bedroom  oc¬ 
cupying  the  whole  width  of  the  house,  or  with  a  space  the  width  of  the  first- 
floor  hall  forming  a  bath  and  toilet  room.  More  often  the  bath-room  is  in  the 
center  of  the  house,  off  the  stair  landing,  if  there  is  an  area  light,  or  in  the  rear 
over  the  kitchen.  The  rooms  over  the  dining-room  and  kitchen,  if  there  be 
one,  have  ample  windows.  The  third  story  resembles  the  second.  The  kitchen 
wing  may  have  on  the  second  floor  a  bath-room  and  one  or  more  bedrooms  with 
adequate  light. 

There  have  always  been,  beyond  closely  built  up  sections,  larger  and  smaller 
detached  houses,  with  ample  windows,  and  often  surrounded  by  large  grounds 
and  even  parks.  Many  fine  suburban  homes  have  had  to  give  place  in  the  course 
of  time  to  the  growing  city.  In  the  last  20  or  30  years,  there  have  grown  up 
in  the  northern  and  western  suburbs,  especially,  large  settlements  of  detached 
houses  with  large  grounds  and  ample  shade  trees,  resembling  the  New  England 
town  or  the  western  cities,  but  on  the  whole,  the  extension  of  the  city  into  the 
suburbs  has  been  characterized  by  the  building  of  rows  of  block  houses. 

HEATING. 

All  single  dwelling  structures  built,  until  very  recent  years,  had  in  nearly 
every  room  a  fire-place,  in  which  was  burned  either  wood  or  coal,  or  to  which 
a  stove  wras  attached.  During  the  last  half  of  the  nineteenth  century,  latrobe 
stoves  (burning  hard  coal,  one  set  in  the  parlor  and  one  in  the  dining-room, 
and  fitted  with  flues  to  convey  heated  air  to  the  rooms  above)  were  very  gen¬ 
erally  used.  First  in  large  and  later  in  small  houses,  these  gave  place  to  the 
cellar  furnace,  heating  first  by  hot  air  and  later  by  the  usual  steam  or  hot- 
water  radiators.  Wood  or  coal  fires  are  still  much  used  in  living  or  sitting 
rooms  by  those  who  can  afford  them. 

TENEMENTS. 

The  comparatively  few  large  tenements  of  the  traditional  type  are  poor  in 
design  and  structure,  and  the  same  is  to  be  said  of  those  made  by  remodeling 
and  adding  back  buildings  to  large  and  often  handsome  old  dwellings,  from 
which  the  owners  or  occupiers  of  former  days  have  moved.  Tenements  of  both 
these  classes  abound  in  dark  hallways,  narrow  passages,  and  dark,  ill-ventilated 
rooms,  and  the  buildings  often  occupy  nearly  the  whole  of  the  lots.  In  some 


PHYSICAL  AND  SOCIOLOGICAL  DATA  CONCERNING  BALTIMORE  29 


districts  whole  blocks  of  houses  have  been  remodeled  into  crowded  tenements. 
Tenements  of  this  type  are  most  common  in  the  old  part  of  the  city  in  the 
district  south  of  Saratoga  Street,  along  Jones  Falls  (both  sides),  and  ex¬ 
tending  well  into  Fell’s  Point;  on  Lexington  and  neighboring  streets  for  some 
distance  west  of  Lexington  Market;  and  in  sections  bounded  by  McCulloh 
Street  on  the  east  and  Orchard  Street  on  the  south,  and  extending  north  and 
west,  particularly  along  Druid  Hill  and  Pennsylvania  avenues.  Tenements 
and  similar  several  family  dwellings  of  these  classes  are  occupied  for  the  most 
part  by  people  of  the  recent  migrations,  especially  Polish  Jews,  Hungarians, 
Russians,  and  some  Poles,  and  others,  who,  on  account  of  their  comparative  lack 
of  means,  have  had  on  their  arrival  to  take  such  quarters  as  were  available.  As 
they  prosper,  they  either  take  better  quarters,  or  move  into  single-family 
dwellings.  The  large  tenement  buildings  so  common  in  New  York  and  in 
many  foreign  cities  are  totally  lacking  in  Baltimore. 

Lodging-houses. — The  practice,  particularly  among  families  with  compara¬ 
tively  large  houses,  wdio  for  one  reason  or  another  desire  to  add  to  their  income, 
to  let  one  or  more  rooms  to  lodgers,  with  or  without  meals,  has  been  common  in 
all  sections  of  the  city,  and  there  are  also  large  numbers  of  typical  boarding¬ 
houses.  In  many  such  cases  this  practice  leads  to  the  use  by  the  family  or  by 
the  lodger  of  crowded  quarters,  often  in  dark  rooms.  In  recent  years  many  im¬ 
migrants  have  crowMed  whole  families  into  one  or  two  rooms  rented  from  fam¬ 
ilies  of  their  own  nationalities.  This  custom  is  said  to  be  particularly  common 
among  Poles,  Polish  Jews,  Russians,  Lithuanians,  and  Hungarians. 

A  lodging  house  of  another  type  is  the  5  or  10  cent  house,  accommodating 
men  on  the  floor,  bunks,  or  beds,  and  commonly  styled  “  flop-houses.”  These 
are  fairly  numerous  near  the  water-front,  and  are  patronized  by  seamen,  oyster- 
men,  ne’er-do-wTells,  and  occasionally  by  tramps.  Their  population  has  been 
relatively  small. 

APARTMENTS. 

In  recent  years,  many  large  and  small  apartments  ha.ve  been  constructed, 
and  numerous  old  houses  have  been  transformed  into  apartments.  All  of  these, 
as  in  other  cities,  vary  widely  in  the  space,  light,  and  ventilation  they  afford, 
and  many  sections  of  the  building  code  of  1908  wTere  aimed  at  the  control  of 
these  and  of  the  lodging  and  boarding  houses. 

LAW  ENFORCEMENT  IN  REGARD  TO  LIGHT  AND  AIR  IN 
DWELLINGS,  AND  TO  PREVENT  OVERCROWDING. 

The  laws  on  these  matters,  which  date  only  from  1886,  have  at  no  time  been 
systematically  enforced.  The  building  inspector’s  office  has  passed  on  plans 
permitting  dark  rooms  and  improperly  lighted  and  ventilated  rooms  in  block 
houses  and  in  apartments,  in  direct  contravention  of  the  ordinance  of  1908. 
The  activities  of  the  Health  Department  from  1916  to  1919,  at  least,  in  regard 
to  boarding  and  lodging  houses  and  apartments,  have  been  confined  to  en¬ 
deavors  to  enforce  the  requirements  in  regard  to  cleanliness,  toilets,  and  the 
like. 

There  are  not  now,  and  there  never  have  been,  any  accurate  data  concerning 
the  proportional  distribution  of  the  population  among  good  and  poor  dwellings. 


30 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


In  periods  of  very  rapid  growth  in  population,  housing  conditions  probably 
always  have  been  inadequate,  with  resulting  overcrowding.  This  has  been  the 
fault  of  the  immigrants,  for  no  reasonable  person  could  expect  the  residents 
to  anticipate  population  movements  and  provide  beforehand  for  uninvited 
guests.  The  immigrant  comes  at  his  own  risk  of  finding  a  home  and  the  means 
to  support  it,  and  he  recognizes  these  limitations.  Residents  build  houses  to 
meet  demands  of  those  with  money  to  fill  their  wants,  and  doubtless  often  before, 
as  from  1910  to  1915,  there  were  in  Baltimore  many  unoccupied  dwellings. 
Certainly  during  that  period  there  was  no  excuse  for  overcrowding,  though  this 
existed  in  many  parts  of  the  city.  How  much  of  this  was  due  to  choice  and  how 
much  to  inability  to  pay  moderate  rents  it  is  impossible  to  estimate  accurately. 

It  may  be  assumed  with  safety  that,  throughout  its  history  as  a  city,  the 
great  mass  of  the  white  population  has  been  reasonably  well  housed,  and  that 
since  an  early  date  most  of  those  of  Anglo-Saxon  descent  have  lived  in  well- 
built  one  family  dwellings,  much  superior  in  room,  air-space,  and  light,  at 
any  given  period,  to  those  obtaining  in  most  European  and  other  American 
cities. 

Representatives  of  other  white  races  have  established  themselves  on  the 
whole  on  the  same  footing,  after  immigration,  as  they  have  found  means. 
The  Germans,  German  Jews,  Irish,  Bohemians,  and  the  Italians  have  achieved 
this  station  in  the  order  of  their  coming;  other  races  are  in  process. 

The  description  of  Wynne  (12),  written  in  1850,  except  for  the  last  sen¬ 
tence,  applies  substantially  today : 

“  The  houses  occupied  by  the  laboring  classes  have  usually  a  16-foot  front,  a  depth  of 
30  or  more  feet,  are  two  to  three  stories  high,  and  are  unvariably  of  brick.  Behind  the 
main  building,  there  is  usually  a  back  building  of  the  same  height,  and  a  yard  with  a 
privy  and  a  hydrant.  (Both  these  now  displaced  in  favor  of  interior  toilets  and  water- 
supply.)  These  houses  are  for  the  most  part  occupied  by  single  families,  but  are  some¬ 
times  underlet  to  poor  persons.  The  system  of  a  number  of  families  occupying  the  same 
house  does  not  prevail  to  the  same  extent  as  in  some  other  places  and  is  confined  to 
the  very  poor.  Whole  streets,  however,  in  the  western  part  of  the  town  are  occupied 
by  a  wretched  population,  crowded  together  in  a  most  unseemly  and  unhealthy  manner.” 

In  so  far  as  the  last  sentence  applies  to  whites,  it  is  probable  that  it  fitted  the 
great  number  of  Irish  and  German  immigrants  forced  to  leave  their  native 
lands  during  the  previous  few  years  and  who  had  been  here  too  short  a  time 
to  establish  themselves.  The  same  fate  of  necessity  overtook  the  crowds  of 
Polish  Jews  who  arrived  in  the  last  two  decades  of  the  nineteenth  century.  This 
must  always  have  affected  those  immigrants  whose  coming  was  influenced  more 
strongly  by  repellant  than  by  appellant  forces,  but  in  each  case  they  have  no 
doubt  found  the  housing  conditions  much  better  than  those  they  left. 

It  has  been  with  the  negro,  however,  that  poor  housing  conditions  have  been 
especially  associated,  and  in  many  ways  with  truth.  It  is  difficult  to  decide  which 
on  the  whole  was  the  better  (or  the  worst)  housed  in  Baltimore,  the  free  or 
the  slave  negro.  For  a  certain  period  the  death-rate  was  greatest  among  the 
latter.  There  was  every  incentive  for  the  masters  of  slaves  to  house  them  as  well 
as  practicable,  and  many  of  the  free  negroes,  both  before  and  after  1865,  were 
skilled  artisans  and  earned  good  wages.  For  the  latter,  the  chief  reason  for 
alley  residence  was  not  financial  but  social.  Indeed,  there  are  many  rows  of 
alley  houses  fully  equal  and  often  superior  to  many  “  street  houses,”  and  when 


PHYSICAL.  AND  SOCIOLOGICAL  DATA  CONCERNING  BALTIMORE  31 


the  family  is  not  too  large  afford  healthy  dwellings.  Again,  within  the  last 
20  years,  many  negroes  have  lived  in  well-built,  large  houses,  on  wide  streets, 
fully  the  equal  of  those  of  many  of  their  white  neighbors,  and  in  every  way 
superior  to  the  crowded  dwellings  of  many  of  the  more  recent  white  immigrants. 
In  every  way  the  negro’s  status  is  racial;  whatever  his  means,  he  was  often 
limited  to  alley  dwellings,  because  on  account  of  opposition  of  the  whites  he 
could  not  gain  entrance  to  a  street  block.  In  most  neighborhoods,  when  one  or 
two  negro  families  succeed  in  getting  a  house  in  such  a  block,  the  whites  will 
move  out,  and  the  whole  block  will  in  a  short  time  be  inhabited  by  negroes. 
Thus  they  have  gained  block  after  block  in  many  streets.  It  is  certain  that  the 
negro,  on  the  whole,  during  the  last  10  or  20  years,  has  been  better  housed  than 
many  whites  of  several  races  of  recent  arrival. 

Ownership  of  the  home  has  been  a  marked  characteristic  of  Baltimoreans. 
This  has  been  facilitated  by  the  ground-rent  system,  by  which  occupation  of  land 
is  obtained  without  immediate  capital  outlay,  the  cheapness  of  building,  and 
the  large  number  of  savings  banks  and  building  and  loan  associations,  ready  to 
lend  money  on  liberal  terms  for  home-building  and  home-owning.  Whereas  in 
some  quarters  of  the  city  many  houses,  even  blocks  of  houses,  are  owned  and  let 
by  large  estates ;  in  general,  building  has  been  carried  on  by  contractors  with  a 
view  to  immediate  sale  to  occupiers.  In  consequence,  a  very  large  part,  probably 
the  majority  of  the  houses  stand  in  the  names  of  the  occupiers.  This  custom  ex¬ 
tends  to  the  so-called  common  laborer.  As  would  be  expected,  under  these  con¬ 
ditions,  in  normal  times  rents  are  comparatively  low. 

Though  overcrowding  undoubtedly  occurs  in  certain  sections  and  among 
certain  race  stocks,  in  general  it  can  not  be  said  to  obtain  for  any  large  section 
of  the  population,  for  according  to  the  United  States  census  of  1910,  there 
were  101,905  dwellings  to  118,851  families  and  a  population  of  558,485. 


PART  II.— HISTORICAL  DEVELOPMENT  OF  THE 
HEALTH  DEPARTMENT  AND  OF  HEALTH 
LAWS  AND  REGULATIONS  IN  BALTI¬ 
MORE  AND  THE  STATE  OF 
MARYLAND. 

Chapter  III. — Ideas  underlying  the  Public  Health 

Laws  of  Baltimore. 

Tlie  early  health  laws  of  Baltimore  were  concerned  entirely  with  prevention 
of  the  entrance  and  spread  of  certain  acute  febrile  diseases.  In  seeking  to  in¬ 
terpret  the  ideas  underlying  these  laws  and  their  administration,  it  is  necessary 
to  review  briefly  the  knowledge  and  beliefs  which  obtained  at  that  time  in 
Europe  and  in  North  America  concerning  the  natural  history,  and  especially 
the  modes  of  dissemination,  of  the  prevalent  communicable  diseases  of  the  time. 
In  Baltimore  and  in  Maryland,  as  along  the  rest  of  the  Atlantic  seaboard,  in 
1797,  the  diseases  of  this  class  most  usual,  most  dreaded,  and  most  written  about 
were  malarial  and  yellow  fevers,  diarrhoea,  dysentery,  and  small-pox.  Of  the 
malarial  fevers,  the  intermittent  and  remittent,  or  bilious  remittent,  were 
common  and  very  fatal.  At  least  two  epidemics  of  yellow  fever  had  been 
recently  experienced.  Small-pox  was  a  constant  menace. 

Typhus  fever,  measles,  scarlet  fever,  and  influenza  are  known  to  have  visited 
the  town  as  occasional  epidemics,  but  had  not  yet  become  endemic.  Whooping- 
cough  and  membranous  croup  were  certainly  endemic,  but  faucial  diphtheria 
was  rare.  Of  the  diarrhoeal  affections,  dysentery,  cholera  morbus,  and  cholera 
infantum  were  prevalent  and  very  fatal.  Charles  Caldwell,  of  Philadelphia, 
writing  in  1802,  stated  that  the  latter  affection  was  far  more  common  and 
more  fatal  in  American  than  in  European  cities  and  suggested  that  it  be  called 
Americana  pestilentia  infantum.  Pulmonary  tuberculosis  was  common,  as  per¬ 
haps  also  was  pneumonia.  Gonorrhoea  and  syphilis  were  well  known.  Typhoid 
fever  had  not  yet  been  differentiated  as  a  distinct  disease.  Bubonic  plague,  in 
typical  form  at  least,  had  never  reached  America,  and  fear  of  this  disease  was 
traditional  only.  Relapsing  fever  and  the  English  sweating  sickness  had  never 
been  recognized  in  Baltimore.  There  were  three  deadly  and  much  feared  “  pes¬ 
tilential  ”  diseases,  small-pox,  yellow  fever,  and  typhus  fever,  against  the  en¬ 
trance  of  which  quarantine  and  other  protective  measures  were  likely  to  be 
invoked. 

Many  of  the  physicians  of  Baltimore  ToAvn  were  men  of  talent,  learning,  and 
keen  powers  of  observation  and  reasoning,  and  a  goodly  proportion  of  them  had 
been  trained  in  England.  They  were  well  acquainted  with  the  great  British 
writers  on  medicine  and  some  were  acquainted  with  the  writings  of  Hippocrates, 
Galen,  and  other  ancients  and  with  the  continental  writers  of  the  sixteenth, 
seventeenth,  and  eighteenth  centuries.  In  regard  to  the  natural  history  of 

33 


34 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


the  diseases  at  present  under  consideration,  the  most  important  writers  who 
influenced  them  were  Thomas  Sydenham,  Richard  Mead,  John  Huxliam,  John 
Pringle,  David  Monro,  John  Lind,  John  Howard,  and  Gilbert  Blane. 

From  Sydenham's  (13)  writings  had  come  down  not  only  his  clear-cut 
descriptions  of  certain  acute  infectious  diseases,  particularly  small-pox,  measles, 
scarlet  fever,  and  malaria,  but  his  ideas,  partly  borrowed  from  Hippocrates 
and  other  ancients  and  partly  his  own,  in  regard  to  the  influence  of  season, 
temperature,  rainfall,  telluric,  and  other  natural  conditions  on  epidemics  of 
disease.  The  teachings  of  Sydenham  which  particularly  influenced  public- 
health  ideas  and  practice  in  Baltimore  were  those  that  held  first,  that  the  kinds 
of  acute  diseases  prevalent  in  any  given  year  were  dependent  upon  the  con¬ 
stitutions  of  the  atmosphere  and  that  the  different  constitutions  of  the  atmos¬ 
phere  and,  consequently,  the  diseases  governed  by  them,  tended  to  run  in  cycles, 
and  second,  that  certain  diseases  were  associated  with  particular  periods  of 
the  year. 

Richard  Mead's  (14)  A  Discourse  on  the  Plague,  dated  November  25,  1720, 
and  written  in  reply  to  an  inquiry  on  the  part  of  the  British  Government  as 
to  the  proper  measures  to  prevent  the  entrance  into  and  the  spread  through  the 
country  of  plague,  had  a  most  profound  influence  upon  the  English-speaking 
world.  The  dreaded  plague  was  at  that  time  raging  in  Marseilles  and,  to  the 
consternation  of  many  continental  and  British  physicians  and  publicists,  it 
was  held  by  the  authorities  and  certain  leading  physicians  of  that  city  to  be 
non-contagious.  It  was  feared  that  the  practical  effect  of  this  heterodoxy 
would  be  relaxation  or  even  abandonment  of  the  usual  methods  and  activities 
against  the  disease,  resulting  in  its  general  spread  over  Europe.  Mead's  recom¬ 
mendations,  which  were  enacted  into  law  on  December  8,  1720,  superseded  the 
former  laws  on  thfs  subject  dating  from  the  time  of  James  I.  As  is  clearly 
shown  from  his  discussion  of  the  subject  and  from  his  later  writings,  Mead's 
“  recommendations,"  as  they  are  commonly  called,  were  based  upon  an  inti¬ 
mate  knowledge  gained  by  travel  in  his  youth  of  the  quarantine  system  of  the 
Mediterranean  seaports,  and  particularly  that  of  Venice,  where  the  system  was 
established  in  1484.  Of  more  importance  than  the  maritime  quarantine  fea¬ 
tures,  however,  were  the  measures  recommended  for  the  local  control  of  the 
plague  should  it  gain  a  foothold  in  the  country.  When  digested,  these  resolve 
themselves  into  13  principles  of  action,  which  cover,  in  all  essential  particulars, 
present-day  procedure  and  practice  employed  in  attempting  to  control  the  con- 
tactive  diseases. 

Pringle  (15)  treated  particularly  of  the  acute  diseases  that  attacked  the 
British  army  and  the  conditions  under  which  they  arose  in  the  campaigns  in 
Flanders  and  in  Germany  in  the  years  1743  to  1748,  inclusive.  He  laid  great 
stress  upon  the  influence  of  wetness  and  dryness  and  of  heat  and  cold  upon 
the  prevalence  and  severity  of  the  diseases  which  he  classed  epidemic.  Pleurisy, 
pneumonia,  and  rheumatism  were  common  in  the  spring,  and  malarial  fevers 
in  the  spring,  summer,  and  autumn.  Dysentery,  often  accompanied  by  liver 
abscess,  was  prevalent,  especially  in  fixed  camps,  in  the  hot,  close  summer 
weather.  He  regarded  this  disease  as  contagious  and  ranked  it  as  among  the 
malignant  and  pestilential  diseases.  It  is  evident  from  his  descriptions  of  the 
anatomical  lesions  that  he  was  dealing  with  both  the  croupous  (bacillary)  and 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  35 

the  severely  ulcerative  (amoebic)  varieties.  He  held  that  “  hospital  fever,”  which 
was  very  prevalent  in  the  crowded  hospitals,  was  identical  with  jail  distemper 
(typhus),  but,  from  his  descriptions  of  cases,  it  would  appear  that  under  this 
name  were  classed  many  cases  of  pyaemia  and  septicaemia  in  connection  with 
wound  infection  and  dysentery.  From  the  frequent  occurrence  of  swelling  of 
the  parotid  glands  as  a  complication  of  malignant  hospital  fever,  it  seems 
likely  that  typhoid  fever  was  also  prevalent.  Of  particular  importance  in  con¬ 
nection  with  the  development  of  methods  designed  to  control  diseases  by  ren¬ 
dering  their  causes  inactive  through  the  action  of  chemical  agents  were  Pringle’s 
exact  experiments  on  the  effects  of  various  substances,  such  as  alkalies,  gums 
(as  myrrh  and  camphor),  Jesuit’s  bark  and  acids,  both  mineral  and  vegetable, 
in  preventing  and  arresting  fermentation  and  putrefaction. 

David  Monro  (16),  writing  of  the  diseases  met  with  by  the  British  forces  in 
the  campaigns  in  Germany  in  1761  to  1763,  dealt  with  the  same  affections  de¬ 
scribed  by  Pringle.  His  observations,  however,  on  the  general  hygiene  of 
camps,  ships,  and  hospitals  were  of  great  importance  and  must  have  exerted  a 
very  decided  influence.  He  laid  especial  stress  upon  bad  water  as  a  cause  of 
disease  in  soldiers.  Next  to  the  unwholesome  vapors  arising  from  marshes 
and  corrupt  standing  water,  he  held  excreta  to  be  the  chief  causes  of  diseases 
in  camps.  He  recommended  that  in  camps  every  precaution  should  be  taken 
to  remove  filth  and  to  provide  proper  latrines,  and  regarded  the  frequent  chang¬ 
ing  of  camping  grounds  as  most  important.  He  gave  definite  and  specific  rules 
for  the  organization  and  management  of  military  hospitals,  particularly  in  re¬ 
gard  to  the  care  and  cleanliness  of  the  patients  and  of  the  bedding  and  floors. 
He  condemned  overcrowding  and  urged  that  provision  be  made  for  purification 
of  the  air  of  wards  by  ventilation  and  otherwise,  that  those  ill  with  contagious 
diseases  be  put  in  separate  wards,  and  that  proper  laundries  be  provided  where 
bedding  and  clothes  could  be  thoroughly  washed  and  aired. 

John  Lind  (17,  18),  the  well-known  authority  on  the  diseases  of  sailors  and 
on  the  hygiene  of  ships  and  hospitals,  and  for  many  years  physician  to  the 
Haslar  Naval  Hospital,  in  a  series  of  papers  published  between  1757  and  1776, 
added  greatly  to  the  knowledge  of  the  natural  history  of  scurvy,  jail  or  ship 
fever,  malarial  and  yellow  fevers,  and  dysentery  and  the  methods  of  their  pre¬ 
vention.  In  regard  to  ship  or  typhus  fever,  he  pointed  out  that  one  ship’s  crew 
was  frequently  infected  from  another  by  the  transfer  of  infected  men,  particu¬ 
larly  of  newly  impressed  men  from  Ireland  and  Scotland,  and  by  visits  of  sea¬ 
men  from  ship  to  ship.  He  recommended  that  these  practices  be  interdicted  and 
that  all  impressed  men  be  held  under  observation  for  a  time  and  be  given 
baths  and  clean  clothes  before  being  assigned  to  ships.  He  laid  great  stress 
upon  proper  cleanliness  and  ventilation  of  ships  and  upon  better  hospital  quar¬ 
ters  on  shipboard.  Lind  established  the  fact  that  ship  fever  can  spread  from 
the  sick  to  the  well  over  no  great  distance  and  that  those  living  in  houses  near 
infected  persons  are  in  no  danger,  provided  communication  be  cut  off.  He 
observed  that  in  the  open  air  the  cause  of  the  disease  did  not  spread  over  50 
feet,  and  that  the  heat  of  an  oven,  such  as  will  destroy  animal  life,  effectually 
destroys  “this  infection.”  He  found  that  the  burning  of  brimstone  over  char¬ 
coal,  used  as  a  method  of  disinfecting  ships  “  does  not  destroy  some  species  of 
vermin,  particularly  lice.”  Lind  showed  that  dysentery  often  attacked  those 


36  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

who  used  privies  that  were  used  by  dysentery  patients,  that  this  disease  often 
spread  rapidly  through  a  hospital  ward  after  the  admission  of  a  dysentery 
patient,  and  that  the  virus  seemed  to  be  spread  particularly  by  the  clothing, 
bedding,  and  utensils  of  dysentery  patients. 

The  intermittent  and  remittent  malarial  fevers  he  held  to  be  the  common 
autumnal  fevers  of  all  hot  countries,  but  perhaps  different  from  yellow  fever. 
To  Lind  belongs  the  credit  of  bringing  to  general  attention  the  value  of  a 
course  of  Jesuit’s  bark  (cinchona)  in  preventing  malarial  fevers,  a  fact  which 
he  stated  had  been  demonstrated  early  in  the  century  by  Kramer,  physician  to 
the  Imperial  army  in  the  campaigns  in  Hungary  (1717-1718)  along  the 
marshy  Danube,  then  one  of  the  sickliest  countries  of  Europe,  and  later  by 
the  English  in  their  “  factories  ”  on  the  Guinea  Coast.  Lind  quoted  three  phy¬ 
sicians  well  acquainted  with  yellow  fever  in  the  island  of  Jamaica,  as  holding 
that  yellow  fever  was  not  contagious,  “  contrary  to  the  opinion  of  the  Ameri¬ 
can  colonists  who  constantly  apprehend  its  importation  from  the  West  Indies 
in  ships  and  in  goods.”  Gilbert  Blane’s  studies  of  the  diseases  of  sailors 
and  of  warm  climates  exerted  an  influence  only  second  to  Lind. 

The  work  of  John  Howard  (19,  20),  the  philanthropist,  emphasized  the  fact 
that  jails  in  Great  Britain  and  Ireland  were  the  particular  homes  and  breeding- 
places  of  fevers,  especially  of  typhus,  and  indicated  the  importance  of  clean¬ 
liness  and  care  in  their  control.  He  also  brought  to  the  general  knowledge  of 
the  English-speaking  peoples  the  elaborate  quarantine  provisions  of  the  Medi¬ 
terranean  ports,  with  their  systems  of  hospitals  and  lazarettos.  To  Howard’s 
influence  has  been  attributed  some  of  the  most  stringent  features  of  the  Brit¬ 
ish  quarantine  system  when  it  was  remodeled  just  about  the  time  that  the 
early  health  laws  of  Baltimore  were  in  the  framing. 

In  regard  to  water-supplies  and  sewerage  disposal,  apparently  the  only 
standards  were  taste  and  a  not  very  highly  developed  sense  of  common  decency. 
It  will  be  recalled  that  after  the  fall  of  Home,  in  the  fifth  century,  the  Euro¬ 
pean  world  well-nigh  if  not  entirely  lost  appreciation  of  the  importance  of  pure 
water  and  of  the  sanitary  disposal  of  human  waste.  It  is  well  established  that 
these  sanitary  practices,  dating  from  at  least  the  time  of  Ninevah,  were  car¬ 
ried  to  the  Greek  cities  by  the  Phoenicians  and  later  were  highly  developed  by 
the  Romans,  who  introduced  them  to  France,  Germany,  and  England.  At  the 
opening  of  the  nineteenth  century,  drinking-water  was  obtained  from  pol¬ 
luted  springs,  wells,  lakes,  and  rivers,  and  the  efficient  use  of  sanitary  sewers, 
on  any  large  scale  at  least,  had  fallen  into  desuetude. 

The  development  of  public-health  administration  in  Baltimore  has  been  so 
intimately  bound  up  with  the  evolution  of  the  conceptions  conveyed  by  the 
terms  of  contagion  and  infection  that  at  this  point  it  is  necessary  to  trace  these 
briefly. 

CONTAGION  AND  INFECTION. 

Diseases  in  general  and,  later,  epidemic  diseases  in  particular,  were  first  as- 
scribed  to  the  will  of  deities,  the  actual  instruments  of  whose  design  or  wrath 
were  thought  to  be  evil  spirits  or  specially  created  poisons.  The  latter  were 
to  be  avoided  by  segregation,  by  flight,  and  by  charms,  and  the  former  were 
to  be  placated  by  penitential  sacrifice  and  worship.  It  is  common  knowledge 
that,  in  certain  countries  of  Europe  where  science  has  not  been  cultivated  and 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  37 

religious  superstition  and  intolerance  have  been  to  but  a  slight  degree  over¬ 
thrown,  those  ideas  are  still  widely  prevalent.  In  illustration  of  the  tenacity 
with  which  these  ideas  may  cling,  even  in  a  country  notable  alike  for  the 
strength  of  religious  superstition  and  ecclesiastical  tyranny  and  for  great  con¬ 
tributions  to  science,  it  may  be  permissible  to  recall  that,  when  cholera  threa¬ 
tened  Scotland  in  1853,  the  Presbytery  of  Edinburgh  addressed  the  Britisli 
Government,  suggesting  the  appointment  of  a  period  of  fasting  and  repen¬ 
tance  with  the  object  of  appeasing  Divine  Providence  and  so  turning  away  a 
pestilence  with  which  a  sinful  people  was  threatened. 

The  idea  of  the  invasion  of  the  body  by  harmful  agents  from  the  outside  is 
of  very  remote  origin.  In  very  ancient  times,  the  peoples  of  the  Mediterranean 
basin,  from  whom  western  civilization  derives  its  origin,  recognized  that  of  the 
great  mass  of  diseases  there  were  some,  especially  those  affections  that  spread 
as  plagues  and  pestilences  and  those  that  were  particularly  identified  with 
certain  places,  which  had  in  common  a  constant  symptom — fever.  It  was  thus, 
no  doubt,  that  all  diseases  fell  naturally  into  one  of  two  groups,  the  febrile 
and  the  non-febrile.  With  expanding  knowledge,  these  groups,  and  the  febrile 
group  more  especially,  were  submitted  to  critical  study  that  led  to  the  recogni¬ 
tion  of  classes  distinguished  by  other  qualities.  Until  very  recent  years,  with 
few  exceptions,  the  great  mass  of  the  diseases  which  man  has  sought  to  avoid  and 
to  control  belonged  to  the  group  of  which  fever  is  a  prominent  symptom.  Hence 
it  occurred  that,  from  their  beginning,  health  departments  were  concerned 
chiefly  with  acute  febrile  diseases,  and  especially  with  those  that  came  from 
without,  such  as  plagues  and  pestilences,  and  the  spread  of  which  experience 
showed  was  directly  associated  with  communications.  The  febrile  diseases 
indigenous  to  places  and  so  long  regarded  as  necessary  evils  received  less  at¬ 
tention  and  were  apt  to  be  treated  with  a  contempt  bred  of  familiarity  or 
accepted  with  a  feeling  of  helplessness. 

At  the  period  of  the  framing  of  the  first  health  laws  of  Baltimore,  a  sharp 
distinction  was  very  generally  recognized  between  those  acute  febrile  diseases 
either  observed  to  be  or  believed  to  be  conveyed  by  direct  or  indirect  contact 
from  the  sick  to  the  well  and  those  for  which  this  method  of  transmission 
was  not  in  evidence  or  was  at  least  denied.  These  conceptions  had  been  grad¬ 
ually  developed  over  a  long  period  of  history.  The  causative  agents  of  the 
contactive  or  contagious  ( con-tango ,  touch)  diseases  were  thought  to  be  emana¬ 
tions  carried  in  some  instances  by  the  breath  and  in  others  by  the  secretions 
or  the  excretions  of  the  bodies  of  the  sick.  These  disease-producing  ma¬ 
terials  might  be  the  products  of  secretions  or  of  poisonous  substances  de¬ 
rived  from  the  breaking-down  (putrefaction)  of  some  elements  within  the 
bodies  of  the  sick.  These  substances  were  generally  held  to  be  specific  for  each 
contagious  disease;  that  is,  the  disease-producing  cause  emanating  from  an 
individual  with  a  particular  contagious  disease  was  capable  of  producing  that 
disease  only  (the  emanations  of  a  small-pox  patient  could  produce  small-pox 
only  and  not  measles  or  scarlet  fever  or  some  other  disease).  The  causative 
agents  for  the  second  class  of  febrile  diseases  were  thought  to  have  their 
origin  in  the  decay,  fermentation,  or  putrefaction  of  dead  organic  matter,  some¬ 
times  vegetable,  sometimes  animal.  It  was  held  that  in  fevers  proceeding  from 
putrefaction  of  organic  matter  outside  of  the  body,  none  of  the  secretions  or 


38 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


excretions  of  the  sick  were  capable  of  producing  the  same  disease  in  others. 
The  atmosphere  was  held  to  be  the  sole  carrier  of  harmful  agents  of  this  class, 
and,  as  it  was  vitiated  or  infected  (inficio- taint,  corrupt,  or  spoil)  with  or  by 
them,  the  term  infectious  diseases  was  applied  to  febrile  diseases  whose  causes 
were  believed  to  be  so  conveyed. 

From  time  immemorial  it  had  been  popularly  accepted  that  the  malarial 
(mala  aria — bad  air)  fevers  were  caused  by  effluvia  arising  from  the  decaying 
vegetable  material  of  marshes  and  other  stagnant  water  or  of  the  soil,  com¬ 
monly  called  marsh  effluvia  or  miasmata  (Greek,  /u'as/xa — defilement).  The 
distinction  between  miasmatic  and  other  epidemics  was  especially  emphasized 
by  Lancisi  (21)  in  his  De  Noxiis  Palidum  Effluviis  in  1717.  This  doctrine  was 
widely  accepted  and  fixed  at  the  beginning  of  the  nineteenth  century,  and,  as  is 
well  known,  remained  in  force  until  recent  years. 

This  sharply  cut  distinction  between  the  terms  contagious  and  infectious  was 
not  universal,  for  Lind  appears  to  use  these  terms  as  having  the  same  meaning, 
and  Robert  Hooper  (22),  writing  in  1803  concerning  certain  diseases  epidemic 
in  London  during  that  year,  asserted  it  as  his  opinion,  “  that  they  are  not  in¬ 
fectious;  that  is,  they  are  not  communicated  from  one  person  to  another.” 
At  the  same  time,  he  attributed  these  diseases  principally  to  causes  existing  in 
the  atmosphere,  “  which  having  induced  certain  diseases  in  the  human  body, 
are  thereby  destroyed,  without  producing  any  state  of  the  body  capable  of  en¬ 
gendering  particles  which  again  can  create  disease ;  so  that  their  action  is  lost, 
after  having  produced  their  first  effects.”  It  will  be  noted  that  his  conception 
of  causation  here  agrees  with  that  prevalent  at  the  time  for  infectious  diseases, 
but  that  he  uses  the  word  infectious  to  convey  the  idea  with  which  contagious 
was  commonly  identified.  According  to  common  usage,  Hooper  would  have 
stated  that  the  diseases  under  discussion  were  infectious  and  not  contagious. 
Indeed,  Hooper,  and  Lind,  too,  in  a  measure,  seem  to  have  anticipated  for  the 
word  infectious  a  meaning  which  much  later  was  very  generally  attributed  to  it, 
namely,  the  capacity  on  the  part  of  a  disease  to  pass  from  one  person  to 
another  by  any  means  whatever. 

Nathaniel  Potter  (23),  in  his  address  before  the  Medical  and  Chirurgical 
Faculty  of  Maryland  in  1817,  very  clearly  brought  out  these  differences  be¬ 
tween  contagious  and  infectious  diseases.  He  pointed  out  that  the  ancient 
physicians,  when  they  spoke  of  contagion  in  connection  with  fevers,  recognized 
no  distinction  between  persons  and  places,  that  the  ancients  in  general  used 
the  ephithet  contagion  in  connection  with  almost  every  fever  which  could  be 
contracted  by  being  in  the  place  where  it  prevailed,  and  that  this  term  was 
never  applied  in  a  personal  sense  to  any  general  diseases  except  plague  and 
the  eruptive  fevers  until  it  was  suggested  for  other  fevers  by  Hieronimus  Fra- 
castorius  in  1547.1 


1  In  this  connection  it  is  interesting  that  both  Potter  and  Maclean  attributed  to  Fracas- 
torius  the  hypothesis  of  febrile  contagion  and  the  fears  which  it  engendered — all  those 
commercial  impositions  under  the  several  forms  of  quarantine,  pest-houses,  lazarettos,  and 
even  banishment — which  were  in  their  opinion  a  disgrace  to  civilized  man.  In  essence,  the 
tale  runs  that  in  connection  with  the  conflicting  interests  at  the  Council  of  Trent  in  1547, 
when,  because  of  the  dissensions  among  the  members,  Fracastorius,  in  order  to  advance  the 
interests  of  his  patron  and  friend,  the  Pope,  declared  that  a  fever  which  had  appeared  at 
Trent  was  eminently  contagious  and  had  a  particular  attraction  for  those  of  noble  blood. 
It  was  claimed  that  these  assertions  of  Fracastorius  in  regard  to  these  two  particular 
attributes  of  this  fever  overwhelmed  with  fear  the  Spanish  bishops  and  the  Emperor’s 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  39 

Fracastorius  (24)  indeed  held  that  all  contagions  were  divided  primarily 
into  three  classes :  (1)  Those  carried  by  contact  alone,  (2)  those  carried  by  con¬ 
tact  and  by  fomes  (as  examples  are  cited  scabies,  phthisis,  alopesia,  and  leprosy), 
and  (3)  those  which,  like  phthisis  and  small-pox,  are  spread  not  only  by  con¬ 
tact  and  by  fomes,  but  at  a  distance. 

Gradually,  the  febrile  diseases  were  assigned  to  one  or  the  other  of  these 
two  classes,  and  at  the  end  of  the  eighteenth  century  the  following  diseases 
were  regarded  as  contagious :  venereal  diseases,  leprosy,  the  plague  or  the 
classical  pest,  elephantiasis,  ophthalmia,  small-pox,  scarlet  fever,  measles, 
whooping-cough,  hydrophobia,  and  mumps.  Typhus  fever,  the  dysenteries,  ma¬ 
lignant  sore  throat,  and  pulmonary  tuberculosis  were  included  in  this  class  by 
some  and  excluded  by  others.  To  the  diseases  of  the  second  class,  or  the  in¬ 
fectious  diseases,  were  assigned  first  and  foremost  the  malarial  fevers  attrib¬ 
uted  to  the  miasmata  arising  particularly  from  decayed  vegetable  matter, 
and,  according  to  many,  dysenteries  and  typhus  fever.  It  is  of  interest  that 
Potter  (23),  in  1817,  excluded  ophthalmia,  plague,  malignant  or  ulcerated  sore 
throat  (diphtheria),  and  typhus  fever  from  the  contagious  diseases.  Anthrax 
and  glanders  were  apparently  regarded  as  of  little  importance  in  man,  and 
cholera  asiatica  had  not  invaded  western  Europe.  When  it  did,  it  was  regarded 
as  non-contagious  by  the  health  officials  of  Baltimore. 

It  is  to  be  observed  that  the  causes  of  disease  included  in  the  first  class  were 
derived  from  persons,  and  therefore  capable  of  being  spread  only  through  them 
and  their  immediate  or  intimate  contactive  environment,  such  as  the  air  im¬ 
mediately  about  them,  their  clothes,  bedding,  utensils,  and  the  like.  As  a  re¬ 
sult  of  the  efforts  to  control  the  spread  of  such  diseases,  great  importance  came 
to  be  attached  to  the  care  of  articles  in  intimate  association  with  the  sick  and 
to  the  purification  by  dilution  or  by  chemical  agents  of  the  air  immediately  sur¬ 
rounding  those  sick  with  or  dead  of  these  affections.  It  would  appear  that  the 
term  fomes  or  fomites  (fuel  or  tinder)  first  applied  to  the  harmful  agents 
themselves  and  only  gradually  came  to  signify  materials  possessing  qualities 
favorable  to  receiving  and  holding  the  causative  agents  of  diseases  of  this 
class.  Attempts  at  control  of  the  spread  of  diseases  of  this  class  were  therefore 
logically  directed  to  the  management  of  persons  and  their  immediate  envi¬ 
ronment.  The  causes  of  diseases  of  the  second  class,  originating,  as  it  was 
believed,  outside  of  living  animal  bodies  from  the  breaking  down  of  organic 
material,  with  the  consequent  escape  of  the  poisonous  agents  into  the  atmos¬ 
phere,  by  which  their  transmission  to  the  living  body  was  accomplished,  were 
to  be  combated  by  interfering  with  development  of  their  causes  and  by  flight, 
or  by  purification  of  the  air,  either  by  ventilation  or  by  chemical  agents.  Pre¬ 
vention  of  these  diseases  was,  therefore,  to  be  accomplished  mainly  by  the  control 
of  environments  favorable  to  the  origin  of  their  causative  agents.  This  could  be 
effected  best  by  measures  of  general  sanitation.  They  were  to  be  avoided  by 
position,  cleaning,  draining,  and  filling.  In  seeking  to  prevent  a  given  febrile 
disease,  the  first  point  was  to  place  it  in  its  proper  category.  Hence,  the  volum- 

delegates  and  thus  contributed  to  the  success  of  the  Pope’s  party  in  their  efforts  to  remove 
the  council  to  the  Pope’s  own  city  of  Bologna.  The  special  point  of  interest  is  that  to  these 
assertions  of  Fracastorius,  made  entirely  for  political  reasons  and  it  is  claimed  without 
basis  in  actual  fact,  were  attributed  such  far-reaching  consequences  and  practices  in 
hygiene. 


40  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

inous  discussions  of  the  older  authors  as  to  whether  a  given  disease  was  con¬ 
tagious  or  infectious  were  not  simply  academic,  but  involved  decisions  of  a 
very  practical  nature. 

It  had  become  very  widely  accepted  that  the  poisons  of  the  contagious  diseases 
were  formed  in  and  by  the  blood-vessels,  and  that  their  chief  portal  of  entry 
to  the  body  was  through  the  skin,  where  they  were  absorbed  by  the  nerves.  The 
poisons  of  the  infectious  diseases  were  supposed  to  enter  through  the  lungs. 
Various  explanations  were  offered  for  the  observed  fact  that  the  poisons  of 
some  of  the  latter  class  of  febrile  diseases  were  most  active  at  night.  The  fact 
that  they  were  par  excellence  air-borne  satisfactorily  explained  the  influence 
of  winds  upon  their  spread. 

While  in  Baltimore  at  least,  during  this  period,  the  miasmatic  or  infectious 
diseases  were  generally  believed  to  be  due  to  the  direct  action  upon  the  system 
of  poisonous  substances  of  a  chemical  nature,  arising  from  putrefaction  of 
dead  organic  matter,  there  were  those  who  held  that  the  deleterious  action  of 
an  atmosphere  impregnated  with  harmful  substances  of  this  origin  was  indirect; 
that  is,  that,  on  account  of  the  presence  of  these  substances  in  the  air,  the  body 
was  unable  to  obtain  from  it  materials  necessary  for  life  with  health.  To 
quote  Beese  (25)  : 

“  When  by  being  exposed  to  a  noxious  atmosphere,  or  the  effluvia  arising  from  putre¬ 
faction,  whereby  the  pabulum  of  life,  the  air,  is  rendered  impure,  or  so  mingled  with 
gases,  that  the  system  does  not  receive  the  necessary  nutriment  from  its  inhalation, 
disease  is  produced;  we  say  the  disease  is  excited  by  infection.  These  diseases  may  be 
contracted  any  number  of  times  by  the  same  individual.” 

According  to  this  doctrine,  infected  or  spoiled  air  was  incapable  of  furnish¬ 
ing  the  physiological  requirements  of  the  body  which  the  latter  is  accustomed 
to  receive  during  respiration;  in  a  peculiar  sense,  therefore,  the  air  was 
“  spoiled  ”  for  its  proper  usage  by  the  body,  and  the  maladies  resulting  were 
deficiency  diseases.  This  conception  of  an  indirect  mode  of  action  of  the  mias¬ 
matic  poisons  in  causing  the  infectious  diseases  conformed,  as  well  as  did  the 
idea  of  their  direct  poisoning  action,  with  the  theory  of  the  efficacy  in  disease 
prevention  of  the  purifying  of  an  “  infected  ”  atmosphere  by  dilution  (ventila¬ 
tion)  or  by  chemicals.  It  also  explained  equally  well  the  observed  fact  that 
patients  ill  with  such  diseases  often  improved  rapidly  or  quickly  recovered  when 
removed  to  a  “  purer 99  atmosphere. 

An  important  distinction  between  the  contagious  and  the  infectious  (mias¬ 
matic)  diseases  was  based  upon  the  observation  that  one  attack  of  one  of  the 
former  commonly  conferred  a  permanent  immunity  against  that  particular 
member  of  the  group,  whereas  an  attack  of  a  member  of  the  latter  group  did 
not.  However,  it  was  acknowledged  very  generally  that  prolonged  residence 
in  localities  where  they  were  prevalent  was  commonly  associated  with  a  toler¬ 
ance  to  the  causal  agents  of  the  infectious  or  miasmatic  diseases.  A  sharp  dis¬ 
tinction  was  recognized  between  this  tolerance  and  the  actual  immunity 
attained  against  one  of  the  typically  contagious  diseases. 

It  was  not  until  long  after  this  time  that  it  became  established  that  for  a 
goodly  proportion  of  the  diseases  included  among  the  contaetive  diseases,  the 
victim  of  one  attack  does  not  acquire  a  lasting  immunity,  as,  for  instance,  in 
the  venereal  diseases.  The  doctrine  held  best,  of  course,  for  certain  acute  exan- 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  41 

thematous  or  eruptive  diseases,  such  as  small-pox,  varicella,  scarlet  fever,  and 
measles. 

A  very  good  idea  of  the  degree  to  which  distinctions  between  contagion  and 
infection  had  been  reached  in  the  United  States  by  1818  was  given  in  the 
publication  of  the  learned  Dr.  Shecut  (26),  of  Charleston,  South  Carolina. 
Shecut  held  that  there  were  two  kinds  of  contagion ;  first,  that  which  is  pro¬ 
duced  by  the  healthy  action  of  the  vessels,  as  of  the  rattlesnake,  viper,  and 
spider ;  and  secondly,  that  which  is  produced  or  formed  by  the  secreting 
arteries  under  pathological  conditions,  as  in  lues,  variola,  and  vaccinia.  The 
contagions,  he  held,  were  only  generated  in  living  animal  bodies  and  were  set 
free  in  sweat,  saliva,  blood,  pus,  or  breath  of  the  diseased.  When  these  con¬ 
tagious  products  of  the  diseased  body  were  absorbed  in  bedding  or  articles  of 
apparel,  they  became  fomites  which  were  just  as  capable  of  reproducing  the 
same  specific  disease  as  the  secretory  or  excretory  product  from  which  the  fomes 
originated.  A  fomes,  then,  was  a  contagion  carried  not  directly  from  person 
to  person,  but  indirectly  from  the  sick  to  the  well  through  the  medium  of  an 
absorbent  material. 

Infections  were  all  generated  by  the  decomposition  of  putrid  vegetable  or 
animal  substances  or  both  combined,  and,  hence,  they  were  the  result  of  the 
processes  of  putrefaction  of  dead  bodies  only.  The  contagions  were  communi¬ 
cable  only  by  contact  or  touch,  with  the  absorption  of  the  virus. 

The  refinement  to  which  the  distinction  between  contagions  and  infections 
and  the  classification  of  these  two  definite  types  of  disease  had  been  carried 
at  this  time  are  well  shown  in  ShecuUs  syllabus  on  page  42  of  the  distinguishing 
characteristics  of  contagions  and  infections  and  of  the  elaborate  classification 
of  these  diseases  into  classes,  orders,  genera,  and  species. 

The  theory  of  the  chemical  nature  of  the  causal  agents  of  the  contagious 
and  infectious  diseases  continued  to  be  generally  accepted  until  well  after 
the  beginning  of  the  last  quarter  of  the  nineteenth  century.  It  received  the 
support  of  the  great  chemist,  Liebig,  who,  likening  these  disease  processes  in 
the  animal  body  to  the  fermentations,  argued  that  they  were  caused  by  fer¬ 
ments.  It  was  on  this  account  that  the  term  zymotic  came  to  be  applied  to  these 
diseases. 

It  should  not  be  forgotten,  however,  that  the  idea  of  a  contagious  principle 
of  a  living  nature,  the  contagium  vivum  or  contagium  animatum,  is  a  very  old 
one.  The  idea  that  certain  diseases  may  be  caused  by  minute  living  organisms 
was  entertained  by  Fracastorius  (24).  In  the  last  quarter  of  the  seventeenth 
century,  it  received  support  from  the  discovery  of  micro-organisms  by 
Kircher  (27)  (1671)  and  by  Leeuwenhoek  (27)  (1675).  Kircher  ascribed  to 
minute  form-like  forms  a  casual  role  in  bubonic  plague.  Lange  and  Haupt¬ 
mann  (27)  soon  after  found  similar  bodies  in  the  foul  lochial  discharges  of 
women  with  epidemic  puerperal  sepsis,  and  they  held  that  other  diseases,  such 
as  measles,  small-pox,  typhus,  and  pleurisy,  were  caused  by  living  contagions. 
Microscopic  parasites  were  held  to  be  the  cause  of  syphilis  by  Andry  (27) 
(1701)  and  of  malaria  by  Lancisi  (21)  (1717).  Plenciz  (27)  (1762)  strongly 
supported  the  theory  that  the  epidemic  diseases  in  general  were  caused  by 
micro-organisms.  Later,  fungi  and  kindred  organisms  were  found  in  the  intes¬ 
tines  of  individuals  with  cholera  and  typhoid  fever,  in  the  lesions  of  puerperal 


SYLLxlBUS. 

Distinguishing  characters  of  contagions  and  of  infections. 


Contagions  are  to  be  distinguished  from  in¬ 
fections. 

1.  In  being  the  product  of  living  ani¬ 

mal  bodies. 

2.  By  being  a  secreted  fluid,  or  other 

matter,  capable  of  reproducing  the 
same  specific  disease. 

3.  In  being  communicable  only  by  con¬ 

tact,  or  by  the  close  approach  of 
persons,  and  by  the  absorption  of 
the  matter,  or  fomites  of  con¬ 
tagion. 

4.  And  that  under  all  circumstances  of 

the  weather,  whether  a  pure  or 
impure  atmosphere,  wet  or  dry, 
hot  or  cold,  etc. 


Infections  are  to  be  distinguished  from 
contagions. 

1.  In  being  the  product  of  dead  organ¬ 

ized  bodies  animal  or  vegetable, 
or  of  both  combined. 

2.  By  being  aerial  fluids  or  gases 

evolved  or  disengaged  from  the 
foregoing,  during  their  decompo¬ 
sition. 

3.  And  are  in  general  only  communi¬ 

cable  through  the  medium  of  an 
impure  atmosphere;  i.  e.,  the  at¬ 
mosphere  which  supports  them. 

4.  Or,  they  are  the  product  of  an  in¬ 

flammatory  constitution  of  the  at¬ 
mosphere,  and  hence  universal. 


Genera,  or  classification  of  contagions  and  infections. 


Contagions. 

Class  I.  Fixed  or  indolent  contagions. 

Order  I.  Tubercula: 

Genus  Elephantiasis. 

Species  1.  Framboesia. 

Species  2.  Coco-bay. 

Order  II.  Squamae: 

Genus  1.  Lepra. 

Genus  2.  Psora,  etc. 

Order  III.  Vitia: 

Genus  Syphilis: 

Species  1.  Chancre. 

Species  2.  Sibbens? 

Species  3.  Laanda? 

Order  IV.  Spasmi: 

Genus  Hydrophobia. 

Species  a.  Rabies. 

Order  V.  Phlegmasiae: 

Genus  1.  Urethritis. 

Genus  2.  Cynanche. 

Species  Cynanche  maligna. 

Genus  3.  Pertussis. 

Genus  4.  Phthisis. 

Species  Pulmonalis. 

Order  VI.  Vesiculae: 

Genus  Vaccinia. 

Class  II.  Volatile  active  contagions. 

Order  1.  Pustulae: 

Genus  Variola. 

Order  II.  Vesiculae: 

Genus  Varicella. 

Order  III.  Exanthemata: 

Genus  1.  Pestis. 

Species  Orientalis. 

Genus  2.  Rubeola. 


Infections. 

Class  I.  Simple  atmospherical  infection ,  or 
that  which  is  the  effect  of  an  atmosphere 
charged  with  simple  septic  miasma  ( vege¬ 
table  effluvia). 

Order  I.  Intermittentes: 

Genus  1.  Quotidiana. 

Genus  2.  Tertiana. 

Genus  3.  Quartana. 

Order  II.  Remittentes: 

Genus  Remittens. 

Variety  Remittens  biliosa. 

Order  III.  Continuae: 

Genus  1.  Synocha. 

Variety  a.  Synochula. 

Variety  b.  Synochoides. 

Genus  2.  Typhus  vel.  Synochus. 

Species  Typhus  mitior. 

Class  II.  Compound  infection,  or  that 
ivhich  is  the  effect  of  the  septic  miasma, 
combined  rvith  azotic. 

Continuation  of  Order  III,  Class  I: 

Genus  Typhus. 

Species  Typhus  endemica,  vel  Iete- 
rodes,  vel  Pestis,  Occidentalis. 

Class  III.  Original  and  primary  infection, 
or  that  which  is  produced  by  azotic  mi¬ 
asma  ( animal  effluvia). 

Continuation  of  Order  III,  Class  I: 

Genus  1.  Typhus. 

Species  Gravior  vel  maligna. 

Variety  a.  Gaol. 

Variety  b.  Ship. 

Variety  c.  Camp  or  lake  fever. 
Genus  2.  Dysenteria. 

Class  IV.  General  or  universal  infection, 
or  that  produced  by  inflammatory  consti¬ 
tution  of  the  atmosphere  without  regard 
to  either  of  the  miasmata. 

Order  Phlegmasia: 

Genus  1.  Catarrhus. 

Species  Catarrhus  epidemica. 

Genus  2.  Typhoid  pneumonia. 


42 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  43 

peritonitis,  in  favus  and  aphthous  ulcers,  and  in  the  disease  of  the  silkworm 
known  as  muskadine  (Bossi,  1837,  and  Boehm,  1838).  Henle  (28,  29)  (1840 
and  1853)  and  John  K.  Mitchell  (30)  (1849)  ably  supported  the  doctrine  of 
the  micro-parasitic  origin  of  the  acute  febrile  diseases.  Mitchell  attributed  the 
“  malarious  and  epidemic  fevers  ”  to  fungi,  rather  than  to  animal  parasites, 
largely  because  of  the  wider  known  distribution  of  the  former.  He  held  that 
the  purely  chemical  theory,  and  particularly  the  ferment  theory  of  Liebig,  were 
totally  inadequate  to  explain  the  established  facts  of  the  natural  history  of 
these  diseases,  especially  the  immunity  that  follows  recovery  from  the  typically 
contact  diseases. 

The  startling  facts  brought  out  between  1850  and  1880  in  the  controversy 
over  the  causation  of  fermentation  and  putrefaction  added  strength  to  the  germ 
theory  of  diseases  of  this  class.  In  the  meantime,  the  finding  by  pathological 
anatomists  of  bacteria  in  the  blood  and  in  the  local  lesions  in  anthrax  ( Pollen  - 
der,  1855;  Devaine,  1863),  and  in  wound  infections  (Rindfleisch,  1866;  von 
Recklinghausen,  1871;  and  by  such  surgeons  as  Cheyne,  Lister,  and  Billroth), 
put  the  germ  theory  on  a  more  substantial  basis.  The  work  of  Pasteur,  Koch, 
and  their  pupils,  in  isolating  and  cultivating  bacteria  from  the  lesions  of  a  num¬ 
ber  of  diseases  and  in  reproducing  identical  affections  in  lower  animals  by 
inoculation  with  pure  cultures;  the  discovery  of  the  Spirocheta  obermeieri 
(spirillum  of  relapsing  fever)  in  1873,  of  the  Plasmodium  malarice  by  Laveran 
in  1880,  and  other  protozoan  parasites  in  the  blood,  and  in  various  lesions  in 
diseases  of  the  lower  animals ;  and,  finally,  the  studies  in  general  and  in  specific 
immunity,  established  the  doctrine  on  a  firm  basis  by  1890.  However,  even 
under  an  overwhelming  mass  of  evidence,  the  old  ideas  died  hard. 

In  rapid  succession,  bacteria  were  identified  as  the  cause  of  not  only  wound 
infection  in  all  its  forms,  including  puerperal  infection,  but  of  tuberculosis, 
gonorrhoea,  typhoid  fever,  cholera,  diphtheria,  pneumonia,  bubonic  plague,  and 
other  important  diseases  in  man  and  the  lower  animals.  Yeasts  and  higher 
fungi  were  found  in  relation  to  the  lesions  in  a  variety  of  affections.  The 
demonstration  of  spirochaetse  as  the  causal  agents  of  syphilis,  yaws,  and  infec¬ 
tious  jaundice  and  the  discovery  that  sub-microscopic  viruses  are  concerned 
writh  the  causation  of  certain  other  communicable  diseases  are  triumphs  of 
recent  years.  With  these  findings  and  the  experiments  made  possible  thereby 
came  not  only  deeper  knowledge  of  natural  and  acquired  immunity  against 
various  febrile  diseases,  and  the  use  of  new  and  more  exact  methods  of  diag¬ 
nosis,  but  various  antitoxic  and  antimicrobic  sera  and  bacterial  vaccines  for 
the  prevention  and  treatment  of  disease.  Long  before  the  germ  theory  had  been 
rehabilitated  by  the  discoveries  of  the  last  30  years  of  the  nineteenth  century,  it 
had  been  established  that  cholera  (1849)  and  typhoid  fever  (1859)  are  com¬ 
monly  spread  by  polluted  drinking-water ;  the  role  of  milk  as  a  vehicle  for  the 
causative  agents  of  scarlet  fever,  diphtheria,  typhoid  fever,  and  cholera  had 
been  discovered  before  1885. 

Satisfactory  explanations  of  many  of  the  mysteries  of  the  epidemiology  of 
certain  diseases  were  afforded  by  the  demonstration  of  the  important  part 
played  by  intermediate  hosts,  mostly  insects,  in  the  spread  of  certain  definite 
microparasites  in  man  and  the  lower  animals — the  cattle  tick  for  that  of  Texas 
cattle  fever  by  Theobold  Smith  and  Kilbourne  in  1893;  the  mosquito  for  that 
4 


44 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


of  the  haematozoa  of  birds  by  Ross  in  1898  and  of  malaria  soon  afterwards; 
the  tsetse  fly  for  that  of  nagana  in  horses  by  Bruce  in  1894;  the  mosquito  for 
that  of  yellow  fever  by  Reed,  Carrall,  Argamonte,  and  Lazear  in  1900;  and  the 
rat  flea  for  that  of  bubonic  plague  by  the  Indian  Plague  Commission  in  1907, 
and  the  louse  for  that  of  typhus  fever  by  Nicolle  in  1909.  It  has  further  been 
shown  since  1900  that  relapsing  fever  is  spread  by  ticks,  bedbugs,  lice,  fleas, 
and  biting  flies,  and  that  Rocky  Mountain  spotted  fever  is  spread  by  ticks. 

The  road  to  these  revolutionary  discoveries  was  made  easier  by  the  extraor¬ 
dinary  advances  in  the  study  of  pathological  anatomy  and  experimental 
pathology  during  the  nineteenth  century,  which  not  only  established  such  im¬ 
portant  diseases  as  typhoid  fever,  tuberculosis,  syphilis,  leprosy,  pneumonia, 
dysentery,  puerperal  fever,  wound  infection,  and  other  inflammatory  affections 
upon  firm  anatomical  and  physiological  bases,  and  pointed  to  their  parasitic 
origin,  but  showed  the  relation  of  the  parasites  to  the  lesions. 

It  is  a  matter  of  importance  in  this  connection  that  for  the  majority  of  the 
acute  febrile  diseases,  and  among  them  some  of  the  most  dangerous,  ranked 
as  contagious  by  both  old  and  recent  authorities — i.  e.,  small-pox,  vaccinia, 
measles,  scarlet  fever,1  hydrophobia,  influenza,  and  typhus  fever — attempts  to 
discover,  in  the  specific  lesions  or  elsewhere  in  the  body,  micro-parasites  under 
conditions  satisfying  the  demands  of  logic  that  they  act  causal  roles  have 
completely  failed.  The  positive  evidence  that  these  affections  are  caused  by 
micro-parasites  is  no  stronger  now  than  in  the  eighteenth  century,  but  the  argu¬ 
ment  in  favor  of  such  etiology  has  been  greatly  strengthened  by  analogy;  that 
is,  in  their  natural  history  they  present  features  so  similar  and  in  some  re¬ 
spects  so  closely  identical  with  those  that  characterize  diseases  for  which  proofs 
satisfactory  to  the  strictest  logical  requirements  for  such  causation  have  been 
established.  For  the  same  reason,  also,  the  argument  by  exclusion  has  gained 
some  additional  weight. 

The  discovery  that  typhus  fever  is  spread  by  the  body-louse  not  only  removed 
this  disease  from  the  class  of  the  typically  contagious  diseases,  but  by  analogy 
placed  it  more  definitely  in  the  category  with  other  diseases  proved  to  be 
caused  by  micro-parasites  transferred  from  one  individual  to  another  by  biting 
insects,  for  the  bites  of  only  those  lice  that  have  infested  individuals  with  typhus 
fever  can  spread  the  essential  cause  of  this  disease.  In  the  lesions  of  poliomye¬ 
litis,  classed  among  the  contagious  diseases  and  known  only  slightly  to  former 
generations,  but  revived  in  widespread  epidemics  in  recent  years,  Flexner  and 
his  coworkers  have  discovered  minute  bodies  which  seem  to  be  the  etiological 
factors.  In  yellow  fever,  classed  among  the  affections  reckoned  as  effluvial  in 
origin,  Noguchi  has  demonstrated  a  spirochete,  which  further  observations 
may  prove  to  be  the  causal  agent. 

In  their  advocacy  of  the  old  thesis  of  contagia  viva  in  the  causation  of  the 
febrile  diseases,  Henle  and  Mitchell  argued  both  by  analogy  and  by  exclusion, 
attempting  by  the  former  to  establish  points  of  similarity  between  these  diseases 
and  certain  affections  of  plants  and  lower  animals  in  which  micro-organisms 
had  been  found  under  conditions  suggesting  or  even  proving  a  causal  relation, 
and  seeking  by  the  latter  to  show  that  of  the  various  explanations  proposed, 

1  Since  this  was  written  the  recent  highly  suggestive  work  of  Dick  and  Dick  and  others 
on  the  causation  and  the  serum  reactions  of  scarlet-fever  has  been  published. 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  45 

this  was  the  only  one  consistent  with  the  ascertained  facts  of  the  natural  his¬ 
tory  of  these  diseases.  At  this  time  the  latter  mode  of  argument  was  the 
stronger  because  it  was  supported  by  the  heavier  weight  of  facts.  With  the 
demonstration  in  rapid  succession  that  a  number  of  diseases,  including  examples 
of  those  classed  as  contagious  and  those  classed  as  miasmatic  or  diluvial,  are 
due  to  micro-parasites,  the  analogical  argument  in  favor  of  like  causation  of  the 
remainder  was  correspondingly  strengthened.  Facts  supporting  both  these 
lines  of  argument  have  become  so  overwhelming  in  recent  years  that  there  is 
no  escape  from  accepting  the  generalization  that  all  the  febrile  diseases  trans¬ 
missible  in  continuous  series  from  one  individual  to  another  must  be  caused 
by  the  action  of  living  parasites. 

In  later  chapters  a  complete  list  of  these  diseases,  in  so  far  as  they  have 
presented  themselves  in  Baltimore,  will  be  given,  and  the  evidence  upon  which 
certain  of  them  are  held  to  be  transmitted  wholely  or  partly  by  contact  will 
be  submitted  to  analysis. 

Gradually  the  term  contagion  lost  and  the  term  infection  gained  in  impor¬ 
tance.  The  former,  losing  its  etiological  significance,  came  to  mean  only  a  par¬ 
ticular  mode  of  conveyance,  namely,  by  intimate  contact.  The  group  of  con¬ 
tagious  diseases  became  limited  to  a  particular  division  of  infectious  diseases. 
The  terms  infectious  and  infection  gained  new  and  broader  meanings.  Infec¬ 
tious  diseases  came  to  include,  for  clinicians,  the  whole  group  of  diseases  charac¬ 
terized  by  fever,  increased  rapidity  of  the  pulse  and  respiration,  intoxication, 
with  or  without  local  inflammatory  lesions;  for  pathological  anatomists  the 
series  of  degenerations  and  acute  congestions  of  various  organs  of  the  body, 
notably  the  heart,  liver,  kidneys,  and  spleen,  and  local  inflammatory  lesions 
occurring  in  febrile  affections  ;  for  bacteriologists  and  hygienists,  all  the  diseases 
proven  or  thought  to  be  caused  by  micro-parasites. 

For  the  clinical  physician  a  disease  is  infectious  if  it  is  capable  of  being 
transmitted  from  one  individual  to  another  by  any  means  whatsoever;  it  is 
contagious  if  it  can  be,  or  usually  is,  carried  by  contact  with  the  sick  or  their 
immediate  environment.  The  “  droplet  infection  ”  of  Fliigge,  by  which  is 
meant  the  transmission  from  one  person  to  another  of  micro-organisms  attached 
to  fine  drops  of  moisture  (saliva,,  mucus,  pus)  propelled  from  the  mouth 
and  nose  in  the  acts  of  talking,  coughing,  and  sneezing,  belongs  under  the 
latter  heading.  The  organisms  are  thus  thrown  so  short  a  distance  that,  in 
effect,  this  method  of  transference  may  be  regarded  as  so  slightly  removed 
from  kissing  or  other  forms  of  actual  touch,  as  to  fall  well  within  the  concep¬ 
tion  of  “contact.”  For  the  clinician,  the  pathologist,  and  the  bacteriologist,  a 
person  or  an  animal  is  “  infected  ”  after  receiving  a  particular  variety  of 
germ  in  numbers  sufficient  to  cause  disease.  But,  for  the  bacteriologist  “  in¬ 
fected  ”  retains  its  original  meaning  of  “  spoiled,”  “  tainted,”  “  corrupted,”  in 
the  special  sense  that  a  germ  capable  of  multiplication  comes  in  contact  with 
a  substance  of  any  kind,  as  nutrient  media,  an  instrument  or  utensil.  It  has 
much  the  same  significance  to  the  surgeon. 

Probably  the  first  clear-cut  definition  of  the  term  infectious  disease  in  the 
modern  sense  was  given  by  Professor  William  H.  Welch  in  his  lectures  at  the 
Johns  Hopkins  Hospital  in  the  spring  of  1890 :  “  An  infectious  disease  is  any 
disease  caused  by  the  entrance  into  and  multiplication  within  the  body  of 


46  PUBLIC  HEALTH  ADMINISTRATION',  ETC.,  IN  BALTIMORE 

pathogenic  micro-organisms.”  This  definition,  as  Professor  Welch  pointed  out 
at  the  time,  excludes  a  large  group  of  affections  caused  by  the  invasion  of  the 
body  by  macroscopic  parasites  of  which  the  worms  are  examples.  For  such 
diseases,  there  is  a  tendency  to  use  the  term  infestion.  Thus  in  modern  usage, 
infection  has  to  do  with  causation  alone  and  omits  all  consideration  of  modes 
of  communication,  while  contagion  deals  only  with  a  particular  mode  of 
transmission,  i.  e.,  by  contact,  and  has  nothing  to  do  with  ultimate  causation. 
Some  of  the  infectious  diseases  are  typically  contagious,  but  many  are  not. 
With  the  adoption  of  a  new  meaning  for  infectious,  its  synonym,  miasmatic, 
fell  into  disuse.  Fomites,  from  being  the  fuel  itself  carried  by  the  absorbent 
material,  came  to  signify  the  material  which  conveys  the  fuel,  a  complete 
reversal  of  meaning. 

To  avoid  the  great  confusion  of  meanings  attending  the  use  of  the  terms 
contagious  and  infectious  as  applied  to  the  febrile  diseases,  especially  among 
the  older  generation  of  physicians  who  could  not  readily  follow  the  rapid  de¬ 
velopment  of  the  new  science  of  micro-parasitology  in  which  they  had  had  no 
training  (and  this  group  included  many  health  officers),  the  terms  communi¬ 
cable  and  transmissible  came  into  use  about  the  beginning  of  the  twentieth  cen¬ 
tury  to  include  the  group  of  affections  caused  by  invasions  of  the  body  by 
vegetable  or  animal  parasites. 

The  idea  that  emanations  from  sewers  were  efficient  causes  of  diseases  natu¬ 
rally  followed  from  the  conception  that  certain  epidemic  diseases  were  due 
to  the  effluvia  arising  from  the  putrefaction  of  dead  organic  material.  There¬ 
fore,  the  emanations  from  either  open  sewers  or  the  traps  of  closed  sewers, 
or  from  privies  and  cesspools  were  regarded  as  particularly  dangerous.  With 
the  development  of  toilets,  wash-basins,  and  bath-tubs  in  houses  connected 
with  sewers,  it  was  not  unnatural  that  cases  of  febrile  illness  developing  in 
these  houses  were  attributed  to  sewer-gas  emanating  from  the  sewers  through 
untrapped  or  improperly  trapped  connections.  The  acute  febrile  diseases 
thought  to  be  thus  caused  were  at  first  either  those  generally  acknowledged  to 
be  infectious  or  miasmatic,  such  as  the  malarial-fever  group,  or  those  included 
in  this  class  by  some  and  among  the  contagious  diseases  by  others,  such  as 
dysentery,  typhoid  fever,  typhus  fever,  and  diphtheria.  To  the  latter  group  the 
term  miasmatic-contagious  was  often  applied.  As  a  result  of  this  conception 
plumbing  construction  and  plumbing  inspection  arose  to  such  great  impor¬ 
tance  in  health-department  administration. 

From  the  foregoing  it  is  clear  why,  in  the  first  health  ordinances,  clear-cut 
distinctions  were  made  between  the  function  of  controlling  disease  through  the 
management  of  persons  and  their  immediate  environment  and  through  the 
general  environment.  To  the  board  of  health  were  assigned  questions  involv¬ 
ing  personal  hygiene  and  to  the  city  commissioners  the  control  of  general 
sanitation. 


Chapter  IV. — Evolution  of  Public  Health  Laws. 


I.  Baltimore  Town. 

II.  Baltimore  City:  The  two  fundamental  ordinances  of  1797 — Ordinance 
No.  11  and  subsequent  amendments  and  additions  dealing  with  the  organi¬ 
zation  of  the  health  department  and  the  duties  and  powers  of  health 
officials,  the  reporting  and  isolation  of  cases  of  communicable  diseases  within 
the  city,  quarantine  of  the  port;  Hospitals  controlled  by  the  city,  and  the 
registration  of  births  and  deaths,  and  of  physicians,  midwives,  and  under¬ 
takers;  Ordinance  No.  15  and  subsequent  amendments  and  additions  dealing 
with  nuisances,  namely,  general  sanitation  on  public  domains — Street  clean¬ 
ing,  garbage,  night-soil  collection  and  disposal,  food  control — Sanitation  on 
private  domains — Privies,  cesspools,  night  soil,  standing  water  and  decaying 
materials,  cellars,  manufactories  injurious  to  health,  garbage,  habitations, 
plumbing,  foods. 

III.  State  of  Maryland:  Contagious  and  infectious  diseases;  Vaccina¬ 
tion;  Medical  practice;  Registration  and  licensing  of  midwives;  Pharma¬ 
cists;  Nurses,  plumbers,  undertakers,  and  barbers;  Registration  of  births 
and  deaths;  Lunacy  commission;  Child  and  other  labor  laws;  General 
nuisances;  Foods;  Building  inspection. 

I.  BALTIMORE  TOWN. 

The  records  of  public-health  activities  in  Baltimore  before  the  elevation  of 
Baltimore  Town  into  Baltimore  City  on  January  1,  1797,  are  scanty.  During 
the  era  of  Baltimore  Town,  the  powers  of  local  self-government  granted  by  the 
legislature  were  comparatively  restricted.  There  is  no  record  of  the  existence 
of  anything  approaching  a  separate  organized  body  with  duties  and  powers  in 
connection  with  public  health  in  the  early  days  of  Baltimore  Town.  Some 
sort  of  control  over  nuisances  of  the  commoner  sort  was  exercised  by  the  town 
commissioners  and  by  certain  special  commissioners,  as  the  commissioners  for 
paving  streets,  for  instance.  In  1745,  an  act  of  the  commissioners  proscribed  the 
running  at  large  of  geese  and  swine  in  the  town.  According  to  Quinan,  the 
town  commissioners  passed  the  following  resolution  in  1750: 

“  Whereas,  several  persons  permit  stinking  fish  and  dead  creatures  or  carrion  to  lie 
on  their  lots,  or  in  the  street  near  their  doors,  which  are  a  very  offensive  nuisance  and 
contrary  to  Acts  of  Assembly,  the  Commissioners,  therefore,  order  the  clerk  to  put  up 
advertisements  to  inform  such  persons  that  they  are  to  remove  the  same. 

“  Resolved,  That  Dr.  Wm.  Lyon  be  a  committee  of  one  to  enforce  the  same.” 

In  1793,  when  yellow  fever  was  prevalent  in  Philadelphia,  Governor  Lee 
appointed  Dr.  John  Ross  and  Dr.  John  Worthington  as  quarantine  physicians, 
the  former  to  regulate  quarantine  by  sea  and  the  latter  by  land.  In  1794,  Gov¬ 
ernor  Lee  appointed  Dr.  Thomas  Drysdale  as  an  additional  quarantine  phy¬ 
sician  for  Baltimore.  On  July  8  of  that  year,  Drs.  Ross,  Worthington,  and  Drys¬ 
dale,  by  orders  of  the  governor,  stopped  all  vessels  at  the  quarantine  station 
established  below  Whetstone  Point.  These  acts  of  the  governor  were  carried 
out  under  Acts  of  the  Assembly  in  1766,  1769,  1777,  and  1784,  empowering 
the  governor  to  establish  quarantine  under  threatened  invasion  of  pestilen¬ 
tial  diseases. 


47 


48  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

According  to  Quinan  (9)  and  Griffith  (3),  a  committee  on  health,  con¬ 
sisting  of  seven  members  was  appointed,  probably  by  the  town  commissioners, 
in  1794.  Quinan  speaks  of  this  health  organization  in  1794  as  the  board  of 
health  and  records  that  on  April  24,  1795,  a  new  board  of  health  was  elected, 
which  adopted  rules  and  regulations  of  quarantine  on  May  7  and  urged  the 
citizens  to  aid  in  enforcing  them.  On  May  7,  1795,  the  legislature  passed  an 
act  empowering  the  appointment  of  a  health  officer  for  the  port  of  Baltimore, 
and  on  July  29,  the  board  of  health  imposed  a  quarantine  on  all  vessels  from 
South  America  or  the  West  Indies  and,  on  August  16,  ordered  that  no  hides  be 
landed  from  vessels  within  the  town  limits. 

It  would  appear  that  the  State  quarantine  officers  acted  harmoniously  in 
concert  with  the  newly  appointed  board  of  health  of  Baltimore  Town,  for 
Quinan  records  that  on  August  15,  1794,  Dr.  Boss  publicly  defended  the  board 
of  health  which  had  been  charged  with  negligence  in  allowing  the  admission 
of  cases  of  yellow  fever. 

All  these  activities  and  measures  grew,  largely  at  least,  out  of  the  serious 
yellow-fever  epidemics  of  the  time.  The  details  of  the  quarantine  system  have 
not  been  preserved,  but  it  is  probable  that  they  were  almost  identical  with 
those  provisions  in  the  first  public-health  ordinance  of  Baltimore  City,  passed 
on  April  7,  1797.  It  is  probable  that  the  board  of  health  of  1795  continued  to 
function  until  it  was  relieved  by  the  new  public-health  organization  provided 
for  in  Ordinance  11,  1797. 

When  Baltimore  Town  became  Baltimore  City,  on  December  31,  1796,  its 
public  health  organization,  therefore,  consisted  of  a  board  of  health  of  seven 
members,  empowered  to  pass  and  enforce  quarantine  regulations,  a  health 
officer  of  the  port,  and  a  small  hospital  at  Hawkins’  Point  for  the  reception  of 
cases  of  “  pestilential  diseases.”  Such  powers  over  nuisances  and  general  sani¬ 
tation  as  existed  had  been  exercised  by  the  town  commissioners. 

II.  BALTIMORE  CITY. 

Soon  after  the  organization  of  the  new  city  government  of  Baltimore  in  1797, 
two  health  ordinances  were  passed,  one  dealing  particularly  with  the  control 
of  diseases  through  persons  and  their  effects,  the  other  with  the  control  of 
nuisances  and  other  matters  of  general  sanitation.  Upon  these  two  basic  ordi¬ 
nances  has  been  modeled  practically  all  of  the  subsequent  local  health  legisla¬ 
tion,  much  of  which  has  been  enacted  in  the  form  of  supplements.  The  gen¬ 
eral  principles  of  these  ordinances  will  be  discussed  separately.  It  is  to  be 
noted  that  they  are  of  a  broad  and  general,  rather  than  of  a  narrow  and  specific, 
character. 

The  opening  declaration  of  general  principles  of  Ordinance  11,  1797,  is 
important  and  shows  that  the  intent  of  the  authorities  was  to  prevent  the  ori¬ 
gin,  introduction,  and  spread  of  “  pestilential  and  other  infectious  diseases.” 
The  placing  of  the  powers  and  duties  of  the  health  department  under  nine 
commissioners  of  health  was  probably  done  with  the  intention  of  having  all 
sections  of  the  city  fully  and  forcibly  represented.  The  hospital  at  Hawkins’ 
Point  had  been  established  some  years  before  as  a  yellow-fever  hospital  in 
connection  with  the  quarantine  instituted  for  that  purpose.  In  the  second 
section  of  the  ordinance  are  enumerated  the  various  kinds  of  nuisances  which 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  49 

it  was  thought  important  to  attempt  to  control,  and  under  this  heading  fell  all 
of  the  items  included  under  the  head  of  general  sanitation  of  that  date.  It 
must  be  regarded  as  a  declaration  of  the  general  principles  of  sanitation.  It  did 
not,  however,  make  it  the  duty  of  the  board  of  health  to  prevent  or  correct 
such  nuisances,  this  duty  being  left  to  the  city  commissioners  as  provided  in 
Ordinance  15.  Sections  3  to  9,  inclusive,  and  section  11  deal  entirely  with  the 
quarantine  of  persons  and  goods  entering  by  land  or  sea.  The  intent  of  these 
provisions  was  to  prevent  the  introduction  of  any  “  contagious  or  pestilential 
disease  ”  from  over  seas.  For  this  purpose,  there  was  provided  a  paid  quaran¬ 
tine  health  officer  to  visit  vessels  before  their  near  approach  to  the  harbor. 
Power  was  granted  to  remove  those  ill  with  contagious  diseases  to  the  hospital 
at  quarantine,  and  communication  between  quarantined  vessels  and  the  city  was 
forbidden.  There  were,  however,  no  provisions  specified  for  cleaning  vessels 
or  disinfecting  cargoes  at  the  quarantine  station.  The  landing  of  damaged 
hides,  damaged  coffee,  and  other  damaged  goods  within  3  miles  of  the  city 
was  interdicted.  It  will  be  noted  that  the  quarantine  applied  to  all  vessels 
from  over  seas  and  to  such  vessels  as  came  from  suspected  places  in  this 
country,  and  that  the  quarantine  period  was  for  only  7  months  of  the  year. 
Vessels  were  not  to  be  indiscriminately  detained  for  the  usual  40  days,  but 
only  long  enough  to  satisfy  the  quarantine  physicians  that  they  were  not 
dangerous.  In  comparison  with  the  elaborate,  strict,  and  inelastic  quarantines 
of  the  Mediterranean  ports,  of  England,  and  of  certain  American  ports,  nota¬ 
bly  New  York  and  Philadelphia,  these  regulations  were  mild.  In  common 
with  the  practice  at  these  ports,  however,  the  belief  was  recognized  that  dam¬ 
aged  goods  bore  direct  relation  to  the  spread  of  the  diseases  the  introduction 
of  which  it  was  sought  to  prevent.  It  would  appear  that  the  entry  of  ordinary 
goods  not  subject  to  putrefaction  was  not  considered  dangerous.  There  is 
reason  to  think  that  the  quarantine  was  chiefly  against  yellow  fever  and  small¬ 
pox  and  perhaps  typhus  fever  and  that  the  plague,  so  feared  by  Europeans  and 
which  had  never  invaded  the  United  States  up  to  this  time,  was  not  considered 
likely  to  be  introduced  into  Baltimore.  This  ordinance  gives  no  indication  that 
the  city  government  at  that  time  had  any  idea  of  attempting  to  combat  by 
restrictive  measures  the  spread  of  any  other  disease  established  within  the 
city  than  the  malarial  fevers. 

Ordinance  15,  1797,  which  deals  practically  with  those  nuisances  mentioned 
in  section  2  of  Ordinance  11,  is  to  be  regarded  as  complementary  to  that  or¬ 
dinance,  but  the  powers  granted  under  it  were  to  be  exercised  by  the  city 
commissioners  and  not  by  the  board  of  health.  This  ordinance  provided  for 
the  cleaning  of  sidewalks  by  abutting  property  owners,  and  interdicted  the 
placing  of  household  or  manufactory  refuse  upon  the  public  streets  and  the 
creation  of  offensive  nuisances  of  various  kinds.  It  directly  aimed  at  the 
prevention  of  the  stagnation  of  water  and  the  decomposition  of  vegetable 
and  animal  matter  upon  either  private  lots  or  public  highways,  and,  finally,  it 
provided  for  the  removal  of  household  refuse  and  for  the  cleaning  of  the 
streets  at  the  expense  of  the  city. 

These  two  basic  health  ordinances  of  the  City  of  Baltimore  have  undergone 
many  modifications  and  amplifications  in  various  details  in  the  123  years 
since  they  were  written.  Considerable  changes  took  place  between  1797  and 
1824,  a  period  marked  by  experimentation  and  shifting  of  opinion.  The 


50 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


changes  in  the  health  ordinances  were  probably  greatly  influenced  by  the  de¬ 
velopment  of  vaccination  against  small-pox  and  by  the  conclusion  reached 
after  much  experience  and  debate  that  yellow  fever  is  not  contagious  and 
not  necessarily  imported,  but  of  local  origin.  To  avoid  confusion  and  useless 
repetition,  the  changes  in  and  additions  to  these  basic  ordinances  will  be 
presented  as  concisely  as  possible  under  the  various  subjects  which  they  con¬ 
cern  and  in  the  order  of  their  appearance  in  the  field  of  the  health  depart¬ 
ment’s  activities. 

Ordinance  11,  Approved  April  7,  1797. 

An  ordinance  to  preserve  the  health  of  the  city,  and  to  prevent  the  intro¬ 
duction  of  pestilential  and  other  infectious  diseases  into  the  same. 

“  Whereas  it  is  found  necessary  in  all  large  cities,  particularly  those  bordering  on  the 
seas,  to  establish  such  laws  and  regulations  as  may  tend  to  preserve  the  health  of  the 
inhabitants.  And  whereas  it  is  of  the  utmost  importance  to  the  commerce  of  this  State, 
that  the  health,  welfare  and  prosperity  of  this  city  be  preserved,  and  that  the  origin, 
introduction  and  spreading  of  pestilential  and  other  infectious  diseases,  be  prevented. 

“  Therefore  be  it  enacted  and  ordained  by  the  mayor  and  city  council  of  Baltimore, 
that  nine  persons  be  appointed  commissioners  of  health,  to  aid  and  assist  the  health 
officer  for  the  time  being,  in  carrying  the  provisions  of  this  ordinance  into  effect,  and 
that  the  said  commissioners  shall  have  the  direction  and  government  of  the  hospital 
established  on  Hawkins’  Point;  shall  be  authorized,  and  they  are  hereby  authorized 
and  empowered  to  establish  such  rules  and  regulations  for  the  government  of  the  said 
hospital,  as  to  them  may  appear  proper  and  necessary ;  to  contract  with  a  suitable  person 
to  superintend  the  same,  and  for  as  many  assistant  physicians  and  nurses  as  circum¬ 
stances  may  at  any  time  render  necessary;  to  provide  medicine  and  all  other  articles 
which  may  be  necessary  for  the  comfort  and  accommodation  of  the  sick;  to  provide 
for  a  ready  communication  between  the  hospital  and  Fort  Whetstone  Point  or  the  city, 
and  to  do  all  other  matters  and  things,  which  by  this  or  any  other  ordinance  they  are 
or  may  be  required  to  do. 

“  Be  it  enacted  and  ordained,  that  all  ponds  of  stagnant  water,  all  cellars  and  founda¬ 
tions  of  houses,  whose  bottoms  contain  stagnant  and  putrid  water,  all  dead  putrefied 
animals  lying  about  the  docks,  streets,  lanes,  alleys,  vacant  lots  or  yards,  all  privies 
that  have  no  wells  sunk  under  them,  all  grave  yards,  tallow  chandleries,  tanneries,  sugar 
boilers,  skin  dressers,  dyers,  glue  boilers,  and  slaughter  houses  not  properly  regulated; 
all  docks  whose  bottoms  are  alternately  wet  and  dry  by  the  ebbing  and  flowing  of  the 
tide,  all  accumulation  of  filth  in  the  streets,  lanes,  alleys  and  gutters  thereof,  all  accu¬ 
mulations  of  vegetable  and  animal  substances,  undergoing  a  putrefactive  fermentation, 
are  hereby  declared  common  nuisances,  productive  of  offensive  vapors  and  noxious 
exhalations,  the  causes  of  diseases,  and  ought  to  be  restrained,  regulated  and  removed. 

“  Be  it  enacted  and  ordained,  in  order  the  more  effectually  to  prevent  the  introduc¬ 
tion  of  pestilential  and  other  infectious  diseases  into  the  city,  that  at  any  time  when 
the  mayor  of  the  city  shall  receive  satisfactory  information  of  the  existence  of  any 
pestilential  or  other  fatal  disease,  in  any  place  on  the  continent,  with  which  the  citizens 
of  Baltimore  may  have  communication  or  connection,  the  mayor  may  and  is  hereby 
authorized  to  issue  a  proclamation,  forbidding  the  entrance  of  all  persons  coming  from 
such  infected  places  into  the  city  or  within  three  miles  thereof,  and  the  citizens  from 
having  any  communication  with  them,  for  at  least  fifteen  days ;  provided  he,  she,  or  they 
cannot  produce  an  approved  certificate  of  their  absence  from  such  place  for  at  least 
fifteen  days  previous  thereto;  and  every  person  wittingly  and  knowingly  offending 
against  the  directions  of  the  said  proclamation  shall  forfeit  and  pay  one  hundred  dollars 
for  every  such  offence,  one-half  to  the  informer  and  the  other  half  for  the  use  of  the  city. 

“  Be  it  enacted  and  ordained,  that  the  health  officer  for  the  time  being  shall,  and  he  is 
hereby,  directed  to  visit  all  vessels  coming  from  beyond  the  seas,  and  all  other  vessels 
coming  from  suspected  places,  in  the  months  of  April,  May,  June,  July,  August,  Septem¬ 
ber,  October,  and  November,  and  where  it  shall  appear  necessary,  detain  the  same  at  or 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  51 


below  the  fort  till  he  hath  made  two  or  more  visits  on  board;  and  if  it  shall  appear  to 
such  health  officer  that  a  further  detention  be  necessary,  he  shall  oblige  the  same  to 
perform  a  quarantine  not  exceeding  twenty  days,  and  in  all  such  cases  the  health  of¬ 
ficer  shall  give  a  certificate  to  the  captain  or  master  of  the  vessel,  signed  with  his 
name,  expressing  the  number  of  days  the  said  vessel  is  to  ride  quarantine,  and  at  or 
before  the  end  of  each  quarantine  the  health  officer  is  hereby  enjoined  to  make  a  second 
visit  to  the  said  vessel ;  and  should  it  appear  to  him  that  a  further  quarantine  is  neces¬ 
sary,  he  is  hereby  authorized  to  enjoin  the  same  for  any  number  of  days  not  exceeding 
ten. 

“  Be  it  enacted  and  ordained,  that  if  the  master  or  other  person  having  charge  of 
any  vessel  bound  to  the  port  of  Baltimore,  having  on  board  any  person  or  persons  dis¬ 
ordered  with  any  contagious  disease,  or  coming  from  any  sickly  port  or  place  without 
a  clean  bill  of  health,  shall  bring  his  vessel  or  suffer  or  permit  the  same  to  be  brought 
nearer  to  the  port  of  Baltimore  than  Hawkins’  Point,  or  shall  land  or  bring  on  shore, 
or  cause  or  suffer  to  be  landed  or  brought  on  shore,  any  such  infected  persons,  or  any 
part  or  parcel  of  their  goods  or  effects,  or  any  other  goods,  until  he  has  obtained  a 
license  or  permit  so  to  do  from  the  health  officer  or  his  assistant,  such  master  or  any 
other  person  having  charge  of  such  vessel  shall  forfeit  and  pay  for  every  such  offence  the 
sum  of  one  thousand  dollars,  for  the  use  of  the  city. 

“  Be  it  enacted  and  ordained,  that  if  any  master  or  other  person  having  command  of 
any  vessel  at  the  time  of  inquiry  by  the  aforesaid  health  officer  or  his  assistant  shall 
have  on  board  any  person  infected  as  aforesaid,  and  shall  knowingly  conceal  the  same,  or 
shall  not  make  a  just  and  true  discovery  to  the  said  health  officer  or  his  assistant  of 
the  sickly  and  disordered  state  of  all  and  every  person  on  board,  from  the  time  the 
said  vessel  departed  from  the  port  or  place  from  whence  she  last  sailed  to  the  time  of 
said  inquiry,  and  of  all  other  particulars  necessary  for  the  said  health  officer  or  his 
assistant  to  know,  respecting  the  premises,  such  master,  or  other  person  having  com¬ 
mand  of  such  vessel,  shall  forfeit  and  pay  for  every  such  offence  the  sum  of  three 
hundred  dollars,  for  the  use  of  the  city. 

“  Be  it  enacted  and  ordained,  that  during  the  detention  of  any  vessel  at  or  below 
the  fort,  by  the  health  officer,  or  during  the  time  of  her  being  ordered  to  perform  quar¬ 
antine  by  him,  it  shall  not  be  lawful  for  any  person  on  board  such  vessel  to  come  on 
shore  and  have  communication  with  any  person,  or  for  any  person  to  go  on  board  such 
vessel  without  the  permission  of  the  health  officer  in  writing;  every  person  offending 
against  the  provisions  of  this  clause  shall  forfeit  and  pay  the  sum  of  twenty  dollars,  to 
be  applied  for  the  use  of  the  city. 

“  And  be  it  enacted  and  ordained,  that  if  any  pilot  shall  conduct  any  vessel  above 
Hawkins’  Point,  having  on  board  above  thirty  persons,  being  passengers  or  servants 
(and  it  is  hereby,  declared  to  be  the  duty  of  each  pilot  to  make  due  inquiry  thereof) 
such  pilot  shall  forfeit  and  pay  one  hundred  dollars  for  the  use  of  the  city,  and  if  any 
pilot  shall  have  knowledge  that  there  is  on  board  any  vessel  that  he  undertakes  to  pilot, 
any  persons  distempered  with  the  plague,  or  any  malignant  contagious  disease,  and  it 
is  hereby  declared  to  be  his  duty  to  make  due  inquiry  thereof,  and  shall  pilot  such 
vessel  above  Hawkins’  Point,  he  shall  forfeit  one  hundred  dollars  for  the  use  of  the 
city;  and  such  pilot  shall  be  disqualified  to  act  as  pilot  for  one  year;  and  if  any  pilot 
shall  have  knowledge  that  there  is  on  board  any  vessel  that  he  undertakes  to  pilot, 
any  person  distempered  as  aforesaid,  and  it  is  declared  to  be  his  duty  to  make  due 
inquiry  thereof,  and  shall  conceal  the  same  from  the  aforesaid  health  officer  or  his 
assistant,  such  pilot  shall  forfeit  one  hundred  dollars,  for  the  use  of  the  city,  and  such 
pilot  shall  be  disqualified  to  act  as  pilot  for  one  year. 

/(  And  be  it  enacted  and  ordained,  that  the  commissioners  of  health  shall  watch  over 
the  health  of  the  city;  and  aid  and  assist  the  health  officer  in  the  discharge  of  his 
duty,  and  carry  into  effect  the  provisions  of  this  ordinance,  and  shall  meet  at  the  court 
house  or  some  other  place  in  the  said  city,  on  the  first  Monday  in  the  months  of  May, 
June,  July,  August,  September,  October  and  November,  or  as  often  as  occasion  may 
require  for  the  purposes  aforesaid,  collect  and  receive  every  possible  information  of  the 
healthiness  of  the  same;  and  the  health  officer  is  hereby  required  then  and  there  to 
meet  them,  with  such  evidences  of  facts  relative  to  his  appointment  as  may  have  come 
to  his  knowledge;  and  the  said  commissioners  of  health  shall  give  all  necessary  assis- 


52 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


tance  to  the  health  officer  in  the  execution  of  his  duty,  cause  all  persons  actually  laboring 
under  infectious  diseases  (and  not  otherwise  provided  for)  to  be  removed  to  the  hos¬ 
pital  on  Hawkins’  Point,  or  elsewhere,  distant  from  the  city  at  least  three  miles,  and 
provide  for  the  infected  such  meats,  drinks,  bedding,  and  clothing  as  may  be  absolutely 
necessary  or  ordered  by  the  health  officer,  and  with  the  advice  of  the  health  officer,  or 
other  practicing  physician  or  physicians,  whom  they  may  consult,  may  take  such  fur¬ 
ther  measures  in  discharging  the  trust  confided  to  them,  as  may  appear  reasonable  and 
proper. 

“  Be  it  enacted  and  ordained,  that  the  health  officer  or  the  commissioners  of  health 
shall  be,  and  they  are  hereby,  authorized  to  prevent  the  landing  of  any  damaged  hides, 
damaged  coffee,  or  other  damaged  goods  from  on  board  any  vessel  whatever,  on  any 
wharf  in  the  city,  or  within  three  miles  thereof,  which  in  their  judgment  would  en¬ 
danger  the  health  of  the  inhabitants.  And  every  person  wittingly  and  knowingly  landing 
any  of  the  same  articles,  contrary  to  the  provision  aforesaid,  shall  forfeit  and  pay  for 
every  such  offence  one  hundred  dollars,  half  to  the  informer  and  the  other  half  for 
the  use  of  the  city. 

“  Be  it  enacted  and  ordained,  that  the  commissioners  of  health  may  appoint  a  clerk, 
and  allow  him  a  reasonable  compensation  for  his  services,  who  shall  keep  fair  minutes 
of  their  proceedings,  and  all  necessary  expenses  incurred  by  them  in  the  discharge  of 
the  duties  herein  required,  which  shall  be  defrayed  by  the  corporation.” 

ORGANIZATION  OF  THE  HEALTH  DEPARTMENT. 

COMMISSIONERS  OF  HEALTH  AND  PRINCIPAL  ASSISTANTS. 

The  ordinance  of  March  20,  1801,  reduced  the  number  of  commissioners  of 
health  from  9  to  5,  2  of  whom  had  to  come  from  that  part  of  the  city  lying 
east  of  Jones  Falls.  The  city  was  divided  into  five  districts,  one  of  which  was 
allotted  to  each  commissioner  for  supervision.  The  commissioners  were  re¬ 
quired  to  meet  as  a  board  of  health  at  least  once  a  week  in  the  months  of 
April,  May,  June,  July,  August,  September,  and  October  for  the  purpose  of 
communicating  and  receiving  all  possible  information  relative  to  the  health 
of  the  city  and  to  advise  and  consult  with  each  other  respecting  its  preserva¬ 
tion. 

The  number  of  commissioners  of  health  was  reduced  to  4  by  the  ordinance  of 
March  22,  1803,  and  their  authority  over  nuisances  on  private  domains,  in¬ 
cluding  docks,  was  considerably  increased. 

According  to  the  ordinance  of  March  17,  1808,  the  position  of  health  (quar¬ 
antine)  officer  was  abolished,  and  the  number  of  commissioners  of  health 
was  reduced  to  2. 

The  powers  and  duties  of  the  city  commissioners  and  the  commissioners  of 
health  were  united  b}^  the  ordinance  of  March  22,  1809,  and  the  new  com¬ 
missioners  were  given  the  power  to  execute  all  the  previously  passed  ordinances 
regulating  the  duties  and  powers  of  the  two  commissions.  By  this  act,  the  con¬ 
trol  of  nuisances  and  matters  of  general  sanitation  were  placed  under  the 
health  department. 

In  the  ordinance  of  March  25,  1814,  it  was  provided  that  the  number  of  com¬ 
missioners  be  increased  from  2  to  3. 

By  resolution  of  the  city  council  passed  December  4,  1817,  the  commissioners 
of  health,  with  other  departments  of  the  city  government,  were  required  to 
make  annual  reports  to  the  council  “  of  the  state  of  the  several  subjects  com¬ 
mitted  to  their  charge  and  to  suggest  such  alterations  and  amendments,  if  any, 
as  may  be  found  by  experience  necessary  in  the  ordinances  connected  with 
their  different  departments.” 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  53 

The  ordinance  of  February  29,  1820,  provided  for  a  consulting  physician,  who 
with  the  three  commissioners  constituted  a  Board  of  Health,  which  was  to 
meet  biweekly  from  March  1  to  November  1  and  bimonthly  from  November  1 
to  March  1.  The  city  was  divided  into  three  sanitary  districts,  each  under  the 
supervision  of  a  commissioner,  who  was  required  to  inspect  at  least  once  every 
two  weeks  from  March  1  to  November  1  all  the  streets,  alleys,  lanes,  wharves, 
warehouses,  cellars,  yards,  lumber  yards,  lots,  docks,  and  all  other  places  he 
might  think  necessary  in  his  district.  Each  commissioner  was  required  to  re¬ 
port  to  the  board  of  health  on  the  general  state  of  his  district  once  in  every  two 
weeks  and  to  enforce  all  the  laws  and  ordinances  in  relation  to  health,  including 
the  abatement  of  nuisances  and  the  duties  in  relation  to  the  health  department 
usually  performed  by  the  city  commissioners,  and  all  others  that  might  be 
required  of  him  by  the  board  of  health  or  the  ma}ror. 

The  duties  of  the  consulting  physician  were  to  give  the  mayor  and  other  city 
authorities  such  professional  advice  and  information  as  they  required,  with 
a  view  to  the  preservation  of  the  public  health,  to  inquire  into  the  health  of  the 
city,  and  when  he  should  hear  of  the  existence  of  any  malignant,  pestilential, 
or  contagious  disease  to  investigate  such  report  and  ascertain  as  correctly  as 
possible  the  causes  which  produced  said  disease,  to  report  this  information  to 
the  board,  and  to  suggest  measures  to  arrest  its  progress,  reporting  to  the 
mayor,  the  board  of  health,  or  the  commissioners  of  the  districts,  as  the  case 
required,  every  circumstance  likely  to  endanger  the  health  of  the  city. 

The  salary  of  the  commissioners  was  $600  each,  and  that  of  the  consulting 
physician  was  $400. 

The  ordinance  of  March  1844  abolished  the  positions  of  the  commissioners 
of  health  and  of  the  consulting  physician  and  assigned  the  duties  of  the  former 
to  the  city  commissioners  and  of  the  latter  to  the  health  or  quarantine  officer. 

By  the  ordinance  of  May  2,  1845,  the  health  department  was  again  reorgan¬ 
ized,  this  time  with  one  commissioner  of  health  and  a  city  physician,  who 
with  the  health  officer  or  quarantine  physician  constituted  a  board  of  health 
to  meet  biweekly  throughout  the  year  with  the  city  physician  as  presiding  of¬ 
ficer.  The  commissioner  of  health  was  to  attend  to  all  the  duties  of  the  health 
office  and  was  to  be  present  at  the  office  of  the  board  from  9  a.  m.  to  1  p.  m. 
every  day,  Sundays  excepted.  He  was  to  keep  a  faithful  record  of  all  matters 
relating  to  the  health  of  the  city,  to  receive  all  reports  from  the  police  of¬ 
ficers  and  others  so  far  as  they  referred  to  the  duties  of  the  health  depart¬ 
ment,  to  enforce  all  ordinances  for  the  preservation  of  health,  and  to  decide 
all  appeals  from  the  reports  of  the  police  officers  by  a  personal  examination  of 
the  premises  in  all  cases  of  dispute.  It  was  the  duty  of  the  city  physician  to 
make  a  circuit  of  observation  once  every  week  to  every  part  of  the  city  and  its 
environs,  in  which  location  or  any  collateral  circumstance  might  be  a  cause 
of  disease,  and  in  all  cases  where  he  discovered  the  existence  of  any  morbific 
agent,  the  presence  of  which  might  prove  dangerous  to  the  health  of  the  city, 
he  was  to  cause  any  ordinance  in  existence  for  its  correction  to  be  enforced. 
If  no  competent  ordinance  existed,  he  was  to  make  a  full  report  to  the  mayor, 
accompanied  with  his  opinion  concerning  the  particular  action  to  be  taken.  It 
was  also  his  duty  to  make  diligent  inquiry  into  all  cases  of  malignant,  infec¬ 
tious,  or  contagious  diseases  which  might  occur  and  to  cause  immediate  mea¬ 
sures  to  be  taken  to  arrest  their  progress  and  generally  to  notice  all  things 


54 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


that  related  to  the  preservation  of  the  health  of  the  city.  It  was  the  duty  of 
the  health  officer,  in  addition  to  such  duties  as  were  required  of  him  by  exist¬ 
ing  ordinances,  to  attend  such  meetings  of  the  board  of  health  as  he  might 
be  requested  to  attend  either  by  the  mayor  or  by  the  president  of  the  board,  to 
inform  the  board  of  anything  demanding  the  attention  of  the  department,  and 
to  advise  with  the  city  physician  on  all  subjects  particularly  “  appertaining  to 
the  sanitary  of  the  maritime.”  The  police  officers  were  required  to  execute  all 
orders  of  the  board  of  health  or  any  member  thereof,  so  far  as  they  referred 
to  the  preservation  of  the  health  of  the  city.  They  were  to  make  daily  in¬ 
spections  in  their  wards  and  report  every  morning  to  the  commissioner  of 
health  and  to  enforce  all  ordinances  for  the  preservation  of  health  within  the 
city.  The  salary  of  the  commissioner  of  health  was  $800  and  that  of  the  city 
physician  $400  per  annum. 

The  ordinance  of  September  4,  1846,  retransferred  to  the  board  of  health 
all  of  the  duties  of  the  city  commissioners. 

The  ordinance  of  February  28,  1861,  combined  the  office  of  city  physician 
and  commissioner  of  health  and  provided  for  an  assistant  commissioner  of 
health,  who,  with  the  commissioner  of  health,  would  constitute  the  board  of 
health.  The  duties  of  the  commissioner  of  health  were  unchanged.  Those  of 
the  assistant  commissioner  were  to  keep  a  faithful  record  of  all  reports  and 
other  matters  of  the  department,  and,  in  case  of  sickness  or  absence  of  the  com¬ 
missioner  or  when  directed  by  the  mayor,  to  perform  the  duties  assigned  to 
the  commissioner.  The  duties  of  the  marine  hospital  or  quarantine  physician 
were  unchanged. 

By  the  ordinance  of  May  23,  1882,  the  health  commissioner  was  authorized 
to  order  all  post-mortem  examinations  and  to  contract  with  two  surgeons  to 
do  this  work.  Later,  provision  was  made  for  a  post-mortem  physician  and  one 
assistant. 

The  mayor  was  made  member  ex-officio  of  the  board  of  health,  the  remain¬ 
ing  members  being  unchanged,  according  to  the  ordinance  of  April  14,  1888. 
The  board  of  health  was  required  to  meet  daily  throughout  the  year.  The 
commissioner  of  health  was  also  made  register  of  vital  statistics. 

The  ordinance  of  May  7,  1894,  empowered  the  commissioner  of  health  to 
appoint  a  chemist  and  three  food  inspectors. 

By  an  ordinance  of  1896,  the  commissioner  of  health  was  authorized  to 
appoint  a  bacteriologist  and  to  establish  separate  chemical  and  bacteriological 
laboratories  in  the  health  department. 

According  to  a  section  of  the  revised  charter  of  Baltimore  City  of  1900, 
the  health  department  was  made  a  subdivision  of  the  department  of  public 
safety,  consisting  of  the  board  of  fire  commissioners,  the  commissioner  of 
health,  the  inspector  of  buildings,  the  commissioner  of  street  cleaning,  and 
the  president  of  the  board  of  police  commissioners,  ex-officio.  The  board  of 
public  safety  was  for  consultation  and  advice  and  had  no  power  to  direct  or 
control  the  duties  or  the  work  of  any  subdepartment.  Section  71  of  this  char¬ 
ter  made  the  commissioner  of  health  the  second  sub-department  of  public 
safety.  The  board  of  health  was  done  away  with,  and  the  commissioner  of 
health  was  given  complete  charge  of  the  health  department,  with  all  of  the 
duties  and  powers  formerly  exercised  by  the  board.  The  commissioner  of 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  55 

health  must  be  a  physician  of  five  years*  experience  and  in  active  practice  at 
the  time  of  his  appointment.  He  may  appoint  two  assistant  commissioners  of 
health,  a  medical  examiner,  and  an  assistant  medical  examiner,  and  a  reason¬ 
able  number  of  clerks  and  subordinates,  and  fix  their  compensation. 

Since  1900,  it  has  been  the  practice  to  establish  new  positions  in  the  health 
department  through  the  annual  ordinances  of  estimates,  instead  of  by  spe¬ 
cial  ordinances. 

VACCINE  PHYSICIANS  AND  HEALTH  WARDENS. 

By  resolution  of  the  city  council,  December  17,  1821,  Drs.  Birkhead,  Coulter, 
Allender,  Jennings,  and  Baker  were  requested  to  act  as  a  commission  to  select 
and  appoint  a  physician  for  each  of  the  six  districts  of  the  city,  “  whose  duty  it 
shall  be  to  obtain  a  full  and  exact  account  of  all  persons  whatever  in  said  dis¬ 
tricts  respectively,  who  have  not  been  vaccinated  or  had  the  small-pox,  to  vac¬ 
cinate  gratis  all  persons  not  competent  in  their  opinion  to  pay  for  it,  and  to 
use  their  utmost  efforts  to  induce  all  others  to  be  immediately  vaccinated  a a 
a  measure  loudly  called  for  by  the  advice  of  the  faculty  and  by  public  neces¬ 
sity.**  The  vaccine  physicians  were  required  “  to  keep  an  exact  register  of  all 
their  vaccinations  and  the  other  material  occurrences  relative  thereto,  and  to 
report  the  same  as  approved  by  the  aforesaid  board  or  commission  to  the  mayor 
and  city  council,  and  to  obey  all  instructions  which  said  board  may  think  proper 
to  give  them,  or  either  of  them,  with  a  view  to  effect  the  full  and  complete  vac¬ 
cination  of  every  individual  within  their  respective  districts.**  These  district 
physicians  received  a  salary  of  not  over  $200  each  and  in  proportion  to  the 
nature,  extent,  and  efficiency  of  their  sendees.  These  provisions  were  made  at 
the  suggestion  of  the  Medical  and  Chirurgical  Faculty  at  the  time  of  a  severe 
small-pox  epidemic  and  were  temporary. 

In  1824,  the  office  of  vaccine  physician  was  made  permanent,  and  in  this 
year  the  commissioners  of  health  were  empowered  to  divide  the  city  into  four 
districts  and  to  appoint  for  each  district  a  vaccine  physician  at  the  salary  of 
$100,  “  for  the  purpose  of  extending  the  benefits  of  vaccination  to  the  indi¬ 
gent  of  our  city.** 

By  the  ordinance  of  March  11,  1853,  the  vaccine  physicians  became  health 
wardens,  and  in  addition  to  their  former  duties  they  were  given  the  general 
supervision  of  the  health  of  their  wards.  They  were  to  look  for  and  report  all 
nuisances  dangerous  to  health,  and  “  whenever  any  disease  of  a  contagious  char¬ 
acter  shall  manifest  itself  in  their  respective  districts,  they  shall,  under  the 
direction  of  the  board  of  health,  use  such  means  as  the  nature  of  the  case  may 
demand  to  arrest  its  progress.**  The  ordinance  of  June  9,  1864,  provided  for 
a  vaccine  physician  for  each  two  contiguous  wards,  who  should  vaccinate  in 
his  wards  all  such  persons  pointed  out  to  him  by  any  member  of  the  board 
of  health  as  susceptible  to  small-pox  contagion  and  whose  duty  would  be  to 
visit  each  dwelling-house  in  his  wards  and  to  vaccinate  every  person  presented  to 
him  for  that  purpose.  He  was  also  required  to  keep  an  office  hour  to  vaccinate 
all  persons  calling  upon  him  for  such  service. 

By  an  ordinance  passed  October  24,  1882,  the  commissioner  of  health  was 
given  power  to  enforce  at  his  discretion  the  vaccination  of  all  persons  not 
previously  vaccinated,  residing  within  the  city,  and  the  vaccination  of  any  per¬ 
son  in  any  infected  district.  Parents  and  guardians  were  required  to  cause 


56 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


their  children  to  be  vaccinated  before  attaining  1  year  of  age  and  revaccinated 
after  5  years  from  the  last  vaccination  whenever  the  commissioner  of  health 
should  order  it.  It  became  the  duty  of  the  vaccine  physicians  or  health  wardens 
to  effect  or  oversee  the  carrying  out  of  these  provisions. 

Section  71  of  the  revised  charter  of  Baltimore  City  of  1900  provided  that 
the  commissioner  of  health  shall  appoint  a  vaccine  physician  for  every  ward 
of  the  City  of  Baltimore,  who  shall  be  a  resident  of  the  ward  for  which  he 
may  be  appointed,  for  the  purpose  of  vaccinating  all  such  persons  in  his  ward 
as  may  be  designated  by  the  commissioner  or  the  assistant  commissioner  of 
health  as  susceptible  to  small-pox  contagion.  All  of  these  vaccine  physicians 
shall  act  as  health  wardens  for  their  respective  wards,  generally  supervise  the 
health  of  their  wards,  and  report  to  the  commissioner  of  health  any  nuisance 
which  in  their  opinion  is  or  may  become  a  source  of  disease,  using  under  the 
direction  of  the  commissioner  of  health  such  means  as  the  nature  of  the  case 
may  demand  to  arrest  its  progress. 

Inspectors. — By  an  ordinance  of  1797,  an  inspector  was  appointed  for  the 
examination  of  salted  provisions  imported  into  and  exported  from  the  City  of 
Baltimore.  The  ordinance  of  October  22,  1883,  provided  for  the  appointment 
of  an  inspector  of  plumbing  for  sanitary  purposes  to  work  under  the  super¬ 
vision  of  the  board  of  health.  The  inspector  was  to  be  a  practical  plumber,  skill¬ 
ful  and  well  trained  in  matters  pertaining  to  the  sanitary  regulations  concern¬ 
ing  plumbing  work.  All  plumbing  work  was  to  be  subject  to  the  supervision  of 
the  inspector  of  plumbing  and  performed  in  no  other  way  than  in  strict  con¬ 
formity  to  such  orders  and  directions  as  might  be  prescribed  by  the  inspector 
of  plumbing  with  the  approval  of  the  board  of  health. 

Four  additional  sanitary  inspectors  were  provided  for  the  twenty-first  and 
twenty-second  wards  by  the  ordinance  of  June  19,  1888. 

Three  inspectors  of  food  were  to  be  appointed,  according  to  the  ordinance 
of  May  16,  1894,  for  the  purpose  of  obtaining  samples  of  milk  and  all  other 
food  products,  the  qualities  of  which  were  to  be  determined  by  chemical  or 
microscopical  examination. 

Under  Section  68  of  the  revised  city  charter  of  1900,  the  commissioner  of 
health  was  given  the  power  to  appoint  a  reasonable  number  of  sanitary  inspec¬ 
tors  for  the  city,  not  exceeding  15 ;  all  inspectors  and  analysts  of  bakeries,  bake- 
shops,  candy  factories,  confectioneries,  or  other  places  for  the  manufacture  of 
similar  food  products,  for  the  purpose  of  ascertaining  their  sanitary  condi¬ 
tions  and  cleanliness  and  the  purit}^,  healthfulness,  and  wholesomeness  of  the 
ingredients  used  in  manufacture,  and  all  inspectors  and  analysts  for  the  proper 
inspection  of  milk,  or  any  and  all  other  food  products  offered  for  sale  in  the 
City  of  Baltimore. 

THE  REPORTING  AND  ISOLATION  OF  CONTAGIOUS  AND  INFECTIOUS 

DISEASES  WITHIN  THE  CITY. 

The  ordinance  of  1797  made  no  allusion  to  the  reporting  of  cases  of  diseases 
within  the  city.  By  the  ordinance  of  March  20,  1801,  practising  physicians 
were  “  invited  ”  to  inform  the  commissioners  of  health  of  the  state  of  health 
of  the  city  and  to  advise  them  in  all  matters  relating  to  the  prevention  of  conta¬ 
gious  diseases.  The  commissioners  of  health  were  given  full  power  to  remove 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  57 

any  person  afflicted  with  a  contagious  disease  dangerous  to  the  community 
to  a  hospital  or  other  place  and  to  prevent  any  kind  of  communication  with 
the  affected  house  or  family  except  by  physicians,  nurses,  or  persons  necessary 
to  carry  medicines  and  provisions.  It  was  made  the  duty  of  the  commissioners, 
when  a  contagious  disease  was  discovered  in  the  city,  to  advertise  the  fact  and 
to  caution  citizens  against  communication  with  the  infected  neighborhood. 
When  such  disease  threatened  to  become  general,  they  could  advise  the  inhabi¬ 
tants  (of  an  infected  district)  to  remove  to  quarters  provided  for  their  recep¬ 
tion — the  poor  to  be  supported  at  public  expense. 

The  ordinance  of  February  10,  1820,  provided  that  “  it  shall  be  the  duty 
of  all  and  each  of  the  practising  physicians  in  the  city  of  Baltimore,  whenever 
any  case  of  malignant,  pestilential,  or  contagious  fever  shall  happen  within  the 
circle  of  their  practice,  forthwith  to  report  the  same  to  the  mayor  or  the  board 
of  health.”  The  penalty  for  non-compliance  was  $100.  This  section  was, 
however,  omitted  in  a  revision  of  this  ordinance  19  days  later,  on  February 
29,  1820.  One  of  the  sections  of  this  ordinance  required  that  every  keeper  of 
a  tavern  or  boarding  or  lodging-house  should  report  cases  of  illness,  occurring 
between  the  first  of  March  and  the  first  of  November,  in  seafaring  men  or  other 
sojourners,  and  masters  of  vessels  lying  in  the  harbor  were  forbidden  to  remove 
any  sick  person  therefrom  without  permission. 

In  1821,  the  board  of  health  was  required  by  ordinance  to  cause  all  districts 
in  which  yellow  fever  was  confirmed  and  beyond  control  to  be  fenced  in  and 
guarded  by  sentinels. 

By  the  ordinance  of  April  25,  1834,  physicians  were  requested  to  report 
to  the  board  of  health  within  24  hours  all  cases  of  small-pox  and  varioloid 
coming  to  their  knowledge,  and  the  commissioners  of  health  were  required, 
whenever  they  met  with  a  case  of  small-pox  which  had  not  been  so  reported, 
to  publish  in  the  newspapers  the  name  of  the  physician  who  had  failed  or 
refused  to  report  it,  but  in  1838,  the  threat  was  omitted.  In  the  code  of  1869, 
even  the  request  to  report  cases  of  small-pox  was  eliminated. 

Compulsory  reporting  of  “  contagious  and  infectious  ”  diseases  on  a  limited 
scale  by  practising  physicians  went  into  effect  after  the  passage  of  the  ordinance 
of  October  24,  1882,  which  required  that  “  every  physician  shall  report  to 
the  commissioner  of  health,  in  writing,  upon  blanks  to  be  furnished  by 
said  commissioner,  every  person  having  small-pox,  cholera,  yellow  fever,  malig¬ 
nant  diphtheria,  or  scarlet  fever,  and  varioloid,  and  his  or  her  place  of  dwelling, 
and  name,  if  known;  such  report  to  be  made  within  24  hours  after  the  first 
visit,  if  such  report  were  not  previously  made  by  some  other  physician.”  By  this 
ordinance,  physicians  were  required  also  to  report  to  the  commissioner  of  health 
the  deaths  of  any  patients  who  had  died  of  contagious  or  infectious  diseases, 
within  24  hours  thereafter,  with  a  statement  of  the  specific  name  and  type  of 
disease.  The  keepers  of  all  hotels  and  boarding-houses,  the  agents  and  owners 
of  all  tenement  houses  or  private  residences  or  dwellings,  and  the  commis¬ 
sioners,  managers,  principals,  or  other  proper  person  or  head  officer  of  every  pub¬ 
lic  or  private  institution  in  the  city  were  required  to  report  in  writing,  within  24 
hours,  to  the  commissioner  of  health,  the  names  and  ages  of  each  and  every 
one  of  the  inmates  of  all  such  houses  suffering  from  any  of  the  above-mentioned 
diseases.  The  same  rules  applied  to  the  masters  and  agents  of  vessels  not  within 


58  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

quarantine,  or  within  quarantine  limits  but  being  within  one-fourth  of  a  mile 
of  any  dock,  wharf,  or  building  of  the  city.  Persons  were  forbidden  to  bring 
to  any  dock,  wharf,  or  building,  or  within  1,000  feet  thereof,  or  to  have  on 
storage  in  the  city  any  skins,  fish,  rags,  bones,  hides,  or  similar  articles  or 
materials  brought  from  any  infected  place,  except  with  the  written  permission 
of  the  commissioner  of  health.  The  sale  of  articles  of  any  kind  that  had  been 
exposed  to  any  contagious  disease  before  they  had  been  adequately  cleansed 
or  disinfected  and  without  a  written  permit  from  the  commissioner  of  health 
was  forbidden.  Without  permission  from  the  commissioner  of  health,  no  person 
sick  with  any  contagious  disease  could  be  carried  from  one  building  to  another 
or  from  any  vessel  to  the  shore.  The  needless  exposure  of  any  individual  to 
those  sick  with  any  contagious  disease  was  forbidden.  Bodies  of  all  persons  dead 
of  any  contagious  disease  were  to  be  buried  within  24  hours  after  death  unless 
this  time  was  extended  by  the  commissioner  of  health,  and  no  such  bodies 
could  be  exposed  to  the  peril  or  prejudice  of  the  life  or  health  of  any  person. 
The  commissioner  of  health  was  instructed  to  give  public  notice  of  infected 
places  by  displaying  a  yellow  flag  on  the  premises  where  infectious  diseases 
existed,  and  he  was  given  the  power  to  remove  any  baggage,  clothing,  bedding, 
or  goods  of  any  character  suspected  of  being  infected  with  any  contagious  or 
infectious  disease.  In  every  case  where  there  had  been  small-pox,  diphtheria, 
scarlet  fever,  or  other  contagious  diseases,  and  the  sick  person  had  either  died 
or  been  removed  from  the  premises  where  the  disease  existed  and  the  occupants 
had  vacated  the  property  without  causing  a  thorough  and  complete  fumigation 
and  disinfection  of  said  property,  the  owners  were  required  to  do  this  before 
any  person  or  persons  could  visit  the  property  with  the  purpose  of  becoming 
tenants  or  owners. 

The  use  of  hackney  coaches,  buggies,  cabs,  and  gigs  for  public  hire  for  the 
removal  of  persons  suffering  from  small-pox,  scarlet  fever,  diphtheria,  or  other 
contagious  diseases  to  or  from  any  point  in  the  City  of  Baltimore,  or  of  any  body 
dead  of  such  diseases,  was  forbidden  under  penalty  of  having  it  or  them  taken 
by  the  commissioner  of  health,  disinfected,  fumigated,  and  quarantined  for 
30  days,  unless  it  or  they  were  used  for  that  purpose  only. 

The  list  of  diseases  reportable  by  physicians  was  expanded  by  the  ordinance  of 
May  20,  1890,  to  include  membranous  croup,  measles,  mumps,  and  whooping- 
cough.  It  is  strange  that  both  typhus  and  typhoid  fevers  were  omitted  from 
these  lists.  The  former  was  surely  known  at  that  time  to  be  a  “  contagious  and 
infectious  ”  disease,  and  had  been  so  held  by  the  health  department  since  its 
establishment,  as  is  seen  from  the  reports  of  the  department. 

On  May  29,  1895,  typhoid  fever  was  by  ordinance  added  to  the  list  of  reporta¬ 
ble  diseases.  The  importance  of  reporting  cases  of  pulmonary  tuberculosis  was 
recognized  by  the  ordinance  of  May  12,  1896.  The  commissioner  of  health  was 
directed  to  register  the  name  and  address,  sex,  and  age  of  every  person  suffering 
from  pulmonary  tuberculosis,  so  far  as  such  information  could  be  obtained, 
and  all  physicians  were  requested  to  forward  such  information  on  cards  ordi¬ 
narily  employed  for  the  report  of  cases  of  contagious  diseases,  this  information 
to  be  solely  for  the  use  of  the  commissioner  of  health.  In  no  case  was  the  com¬ 
missioner  of  health  to  assume  any  sanitary  surveillance  of  such  patients  unless 
the  patients  resided  in  tenement  houses,  boarding-houses,  or  hotels,  or  unless 
the  attending  physician  requested  that  an  inspection  of  the  premises  be  made. 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  59 


In  no  case,  unless  the  patient  resided  in  a  tenement  house,  boarding-house,  or 
hotel,  could  any  inspection  be  made  if  the  physician  requested  that  no  visits 
be  made  by  inspectors  and  was  willing  himself  to  deliver  the  circulars  of  infor¬ 
mation  designed  to  prevent  the  communication  of  the  disease  to  others.  This 
lame  ordinance  was  passed  after  vigorous  effort  on  the  part  of  the  officials 
of  the  health  department  and  a  few  prominent  physicians  and  laymen  and 
against  considerable  opposition.  It  gave  the  health  department  but  little  power 
of  control  over  the  individuals  affected  with  this  disease  and  bore  all  the  ear¬ 


marks  of  having  been  written  by  those  opposed  to  such  control. 

An  ordinance  directed  against  indiscriminate  expectoration  was  passed  on 
February  21,  1905.  It  contained  the  following  provisions:  It  shall  not  be 
lawful  for  any  person  to  expectorate  or  spit  in  or  upon  any  paved  sidewalk  or 
brick  path  of  any  public  street,  avenue,  or  public  square  in  the  city  of  Balti¬ 
more,  or  in  or  upon  any  park  or  any  building  under  the  control  of  the  mayor 
and  city  council  of  Baltimore  City,  or  upon  the  floor,  platform,  or  steps  of  any 
street-railway  car,  or  other  vehicle  carrying  passengers  for  hire,  or  upon  the 
floor  of  any  depot  or  station,  or  upon  the  station  platform  or  stairs  of  any  ele¬ 
vated  railroad  or  other  common  carrier,  or  upon  the  floor  or  steps  of  any 
theater,  store,  factory,  or  any  building  which  is  used  in  common  by  the  public, 
or  upon  the  floor  of  any  hall  or  office,  in  any  hotel  or  lodging-house  which  is 
used  in  common  by  the  guests  thereof.  Corporations  or  persons  owning  or  man¬ 
aging  any  of  the  above-mentioned  public  vehicles  or  buildings,  etc.,  are  required 
to  keep  posted  permanently  and  conspicuously  in  such  places  notices  prohibit¬ 
ing  spitting  on  floors,  etc.  Sufficient  and  proper  receptacles  for  expectoration 
must  be  provided  which  shall  be  cleansed  and  disinfected  once  in  every  24  hours. 

All  other  diseases  now  reportable  have  been  made  so  either  by  act  of  the  State 
Legislature,  or  by  resolution  of  the  State  board  of  health,  which  acts  or  reso¬ 
lutions  apply  to  the  whole  State.  In  1920,  the  list  of  diseases  notifiable  in 
Maryland  included : 


Anthrax  (malignant  pustule). 
Bubonic  plague. 

Cerebro-spinal  meningitis  (epidemic). 
Chancroid. 

Chicken-pox. 

Cholera  (Asiatic). 

Dengue  (breakbone  fever). 
Diphtheria  (membranous  croup). 
Dysentery  (acute). 

Erysipelas. 

German  measles. 

Glanders  (farcy). 

Gonorrhoea. 

Influenza  (grippe). 

Leprosy. 

Malaria. 

Measles. 

Mumps. 


Ophthalmia  neonatorum. 

Pellagra. 

Pneumonia  (lobar). 

Pneumonia  (broncho). 

Poliomyelitis  (infantile  paralysis). 
Rabies  (hydrophobia). 

Relapsing  fever. 

Scarlet  fever  (scarlatina,  scarlet  rash). 
Septic  sore  throat. 

Small-pox  (variola,  varioloid). 
Syphilis. 

Trachoma. 

Tuberculosis  (report  on  special  card). 
Typhoid  fever. 

Typhus  fever. 

Venereal  diseases. 

Whooping-cough . 

Yellow  fever. 


QUARANTINE  OF  THE  PORT. 

A  resolution  of  the  mayor  and  city  council  of  Baltimore,  approved  March  19, 
1801,  instructed  the  mayor  to  apply  to  the  United  States  Government  for 
purchasing  suitable  warehouses  with  the  requisite  wharves  and  inclosures  at 
5 


60 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


some  convenient  place  near  the  port  of  Baltimore  where  goods  and  merchandise 
could  be  unladen  in  accordance  with  the  city  ordinances. 

An  ordinance  of  the  same  date  amplified  the  quarantine  provisions  of  the 
original  ordinance,  the  most  important  section  stating : 

“  And  be  it  enacted  and  ordained,  that  all  vessels  coming  from  either  of  the  Indies, 
the  coasts  of  Africa  and  South  America,  or  any  port  or  place  in  the  Mediterranean,  or 
the  seas  or  waters  connected  with  the  same  to  the  eastward  of  the  Straits  of  Gibraltar, 
including  all  and  every  other  port  or  place  on  the  western  side  of  Spain  as  far  as  Cape 
St.  Vincent,  from  the  first  of  May  to  the  first  of  November,  shall  perform  a  quaran¬ 
tine  of  3  days,  during  which  time  the  health  officer  shall  be  compelled  to  pay  them  a 
visit  daily,  wind  and  weather  permitting,  and  if  at  the  last  visit  a  further  detention  be 
necessary,  he  shall  oblige  the  same  to  continue  their  quarantine,  not  exceeding  10 
days;  and  in  all  such  cases  the  health  officer  shall  give  a  certificate  to  the  master  or 
captain  of  the  vessel,  signed  with  his  name,  expressing  the  number  of  days  the  said 
vessel  is  to  ride  quarantine;  and  the  health  officer  is  hereby  enjoined  to  pay  another 
visit  to  the  said  vessel  before  the  expiration  of  her  quarantine,  and  if  necessary  to 
continue  the  same  any  number  of  days  not  exceeding  5  days  for  each  quarantine.” 

Vessels  arriving  from  the  West  India  Islands,  or  other  parts,  in  the  months 
from  June  to  October,  inclusive,  and  loaded  with  coffee  liable  to  damage  or  pu¬ 
trefaction,  were  not  allowed  to  come  into  port,  but  their  cargoes  were  landed  and 
aired  or  discharged  into  other  vessels  while  remaining  in  the  river,  or  in  the 
“  bite  ”  within  or  near  Love’s  Point,  except  when  special  permission  was  granted 
by  the  mayor  with  the  approbation  of  the  commissioners  of  health.  All  the  ves¬ 
sels  arriving  from  the  ports  or  places  enumerated  in  that  section  of  this  ordi¬ 
nance  previously  referred  to  were  to  discharge  their  cargoes  and  ballast  at  the 
quarantine-ground  in  houses  for  this  purpose,  under  the  inspection  of  a  health 
officer  and  representatives  of  the  custom  house,  before  they  could  be  brought  to 
the  city.  The  ship  and  the  wearing  apparel  of  every  person  on  board  were  to  be 
well  cleansed  and  ventilated  before  persons  could  obtain  a  permit  from  the  health 
officer  to  come  to  the  city.  Persons  sick  or  in  a  disordered  state  on  vessels  were 
to  be  sent  to  the  hospital,  or  such  lazaretto  as  would  be  provided  for  them, 
and  the  board  of  health  was  empowered  to  obtain  the  necessary  provisions  and 
other  articles  for  the  accommodation  of  the  sick.  No  disordered  person  so 
detained  could  leave  the  lazaretto  or  hospital  without  the  permission  of  the 
attending  physician  in  writing.  Vessels  required  to  perform  quarantine  were 
permitted  to  send  their  letter-bags  to  the  post-office  by  the  health  officer  in  such 
manner  as  the  board  of  health  directed. 

The  quarantine  officer  and  his  assistant  were  required  by  the  ordinance  of 
March  18, 1807,  to  be  at  Fort  McHenry  every  day  between  8  a.  m.  and  6  p.  m.,  if 
not  otherwise  engaged  in  the  discharge  of  their  duties.  The  quarantine  officer 
was  required  to  enter  into  a  book  kept  for  the  purpose  all  marine  intelligence 
obtained  from  the  masters  of  vessels  arriving  at  the  quarantine-ground.  This 
book  was  to  be  kept  open  in  his  office  for  the  examination  of  every  person. 
The  health  officer  was  required  to  visit  all  vessels  immediately  upon  their 
arrival,  wind  and  weather  permitting,  coming  from  beyond  the  seas  or  from 
places  where  contagious  disease  was  suspected  to  exist,  from  the  last  of  April 
to  the  first  of  November  of  each  year. 

The  ordinance  of  March  17,  1808,  repealed  such  part  of  the  recently  passed 
health  ordinance  as  required  the  quarantine  of  vessels  and  appointment  of 
a  health  officer  (quarantine  physician). 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  61 

According  to  the  ordinance  of  May  5,  1809,  permission  was  hereafter  to  be 
obtained  from  the  mayor  to  bring  into  port  vessels  loaded  with  articles  liable  to 
damage. 

The  new  health  ordinance  of  February  29,  1820,  which  was  passed  after  the 
great  yellow-fever  epidemic  and  was  drawn  up  under  the  influence  of  the  sug¬ 
gestions  of  the  committee  of  the  Medical  and  Chirurgical  Faculty,  contained 
no  reference  to  quarantine. 

The  ordinance  of  March  14,  1821,  provided  that  all  vessels  with  passengers 
from  sea  voyages  should  be  subject  to  the  orders  of  the  Board  of  Health  which 
could  authorize  the  landing  of  persons  in  perfect  health. 

According  to  the  ordinance  of  March  27,  1821,  no  ballasts  could  be  landed 
from  ships  between  May  and  October,  until  permission  was  obtained  from  the 
Board  of  Health. 

Quarantine  was  reestablished  by  the  ordinance  of  March  11,  1823,  which  pro¬ 
vided  that  all  vessels  arriving  from  foreign  ports  or  places  and  all  coasting- 
vessels  should  come  to  the  quarantine-grounds  until  boarded  by  the  health  of¬ 
ficer,  who  was  required  to  retain  such  vessels  until  he  was  satisfied  that  no 
vegetable  substances  in  a  putrid  state  or  other  damaged  articles  were  on  board. 
If  the  conditions  of  the  vessels  or  cargoes  were,  in  his  opinion,  such  as  to  en¬ 
danger  the  health  of  the  city,  he  was  required  to  order  such  airings  and  cleans¬ 
ings  at  the  lazaretto  as  he  might  deem  necessary.  All  vessels  found  in  a  safe 
and  clean  condition  and  all  coasting-vessels  from  the  eastward  of  Cape  Charles 
and  the  vessels  from  the  southward  laden  with  naval  stores  and  lumber  only 
were  permitted  at  the  discretion  of  the  health  officer  to  pass  up  into  any  part 
of  the  basin  without  restriction,  but  not  within  200  yards  of  any  wharf  on 
the  north  side  of  the  basin.  Here  such  vessels  came  under  the  jurisdiction  of  the 
commissioner  of  health,  without  whose  permission,  given  after  an  examination 
of  their  cargoes,  they  could  not  unload.  The  commissioner  might  cause  such 
vessels  to  be  cleaned  before  coming  to  any  of  the  wharves  or  docks  of  the  city. 
Commissioners  of  health  were  not  allowed  to  permit  the  unloading  of  any  cargo 
arriving  from  the  West  Indies,  Hew  Orleans,  Florida,  South  Carolina,  Georgia, 
the  Gulf  of  Mexico,  or  South  America,  at  any  wharf  on  the  north  side  of  the 
basin  or  harbor,  or  on  the  south  side  to  the  eastward  of  Harbougbis  Wharf. 
These  quarantine  measures  were  applicable  from  the  first  of  May  to  the  first  of 
November.  One  section  of  this  ordinance  provided  that  every  public  or  private 
armed  vessel  sailing  under  commission  and  every  vessel  having  more  than  15 
passengers,  arriving  from  sea,  were  to  land  their  ballasts,  empty  their  water- 
casks,  and  cleanse  them  while  at  the  quarantine  or  at  the  lazaretto,  so  that 
timber  boards  could  be  taken  up  and  the  timbers  well  cleansed  and  approved  by 
the  aforesaid  officer  before  such  vessel  would  be  permitted  to  come  to  any  wharf 
or  dock  within  the  limits  of  the  city.  Vessels  whose  ballasts  consisted  of  salt 
were  exempted  from  these  provisions. 

By  an  ordinance  of  March  24,  1826,  all  the  better  features  of  the  old  quaran¬ 
tine  laws  were  reenacted  and  the  whole  matter  of  quarantine  was  put  in  charge 
of  the  health  officer  (quarantine  physician),  under  the  commissioners  of  health, 
who  were  to  decide  whether  and  to  what  degree  quarantine  was  to  be  imposed 
on  coastwise  vessels  and  vessels  from  foreign  ports.  All  such  vessels  were  re¬ 
quired  to  anchor  at  or  near  Love  Point  for  inspection  by  the  health  officer,  who. 


62  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

after  examination  of  their  crews  and  of  the  condition  of  the  cargoes  and  ves¬ 
sels,  passed  them  if  he  considered  them  safe.  Otherwise,  the  vessels  went  to 
the  lazaretto  for  cleaning,  where  the  cargoes  and  passengers  were  discharged. 
Here,  any  sick  were  to  be  separated  from  the  well.  Private  armed  vessels  or 
vessels  having  more  than  15  passengers  were  required  to  submit  to  the  conditions 
of  the  previous  ordinance  applying  to  them.  The  lazaretto  was  lost  by  fire  in 
1836. 

According  to  the  ordinance  of  May  27,  1847,  the  health  officer  was  to 
inspect  all  passengers  and  passenger  ships  from  foreign  countries,  and  whenever, 
in  his  opinion,  the  health  of  the  city  might  be  endangered  either  from  the 
absolute  presence  of  disease  or  from  an  unclean  condition  of  the  ship  or  pas¬ 
sengers,  he  was  empowered  to  require  such  ship  to  come  to  anchor  at  the  quar¬ 
antine-ground  and  undergo  the  usual  procedures.  It  would  appear  from  this 
ordinance  that  the  quarantine  at  this  time  extended  only  to  passenger  vessels. 

The  ordinance  of  June  18,  1847,  made  it  unlawful  to  carry  from  any  ship 
through  any  street,  lane,  or  alley  of  the  city  any  person  or  persons  infected 
with  any  infectious  disease.  Ho  material  change  occurred  in  the  ordinances 
relating  to  quarantine  until  June  20,  1874,  when  it  was  provided  in  the  revised 
ordinances  that  vessels  arriving  from  points  north  of  Cape  Henry,  free  from 
epidemical  or  contagious  diseases,  and  with  cargoes  from  said  ports,  should 
not  be  subject  to  the  usual  quarantine  regulations,  unless  in  the  judgment  of 
the  board  of  health  compliance  with  these  stipulations  would  be  necessary  to 
protect  the  health  of  the  city. 

From  this  date  until  the  quarantine  regulations  and  practices  of  the  country 
were  made  uniform  and  under  the  general  direction  and  with  the  cooperation 
of  the  United  States  Marine  Hospital  Service  and  its  successor,  the  United 
States  Public  Health  Service,  no  material  changes  were  made. 

REGISTRATION  OF  BIRTHS  AND  DEATHS;  DEATH  CERTIFICATES;  PER¬ 
MITS  FOR  BURIAL  AND  TRANSPORTATION  OF  DEAD  BODIES; 

REGISTRATION  OF  PHYSICIANS,  MIDWIVES  AND 

UNDERTAKERS. 

By  ordinance  passed  October  6,  1874,  and  effective  January  1,  1875,  it  was 
required  that  deaths  occurring  within  the  city  should  be  reported  to  the  com¬ 
missioner  of  health  within  48  hours  by  the  physician  in  attendance,  or  in  suit¬ 
able  cases  by  coroners,  and  that  persons  practicing  midwifery  should  similarly 
report  each  month  all  births  attended  by  them.  In  the  case  of  births  unattended 
by  a  physician  or  midwife,  the  duty  of  reporting,  except  in  the  case  of  births 
and  deaths  of  illegitimate  children,  devolved  on  the  father  or  mother  of  the 
child.  On  death  certificates  it  was  required  to  record  the  full  name  of  the  de¬ 
ceased  (and  if  a  minor  the  name  of  his  father  and  mother),  his  color,  sex, 
age,  occupation,  social  state,  birthplace,  date  and  cause  of  death,  the  ward, 
street,  and  number  of  the  residence,  and  the  dates  of  burial,  certification,  and 
registration.  These  certificates  conveyed  directly  to  the  health  department  the 
information  concerning  deaths  which  had  hitherto  been  furnished  it  through 
the  sextons  of  cemeteries.  This  new  law  also  placed  interments  and  disinter¬ 
ments  directly  under  the  control  of  the  commissioner  of  health. 

Birth  certificates  were  required  to  give  the  full  name  and  the  sex  and  color 
of  the  child,  the  full  names  of  the  father  and  mother,  the  day,  month,  and 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  63 


year  of  birth,  the  street  and  number  of  house  where  born,  the  name  and  resi¬ 
dence  of  the  physician,  midwife,  or  other  person  signing  the  certificate,  and 
the  date  of  certification  and  registration. 

To  further  the  carrying  out  of  these  provisions,  physicians,  midwives,  un¬ 
dertakers,  and  sextons  of  cemeteries  were  obliged  to  register  their  names  and 
residences  at  the  health  office.  Uniform  certificate  blanks  for  deaths  and  births 
were  supplied  by  the  commissioner  of  health.  They  were  modified  but  little  un¬ 
til  the  introduction  of  the  standard  certificates  of  the  Bureau  of  the  Census. 
The  original  law  was  amplified,  but  in  relatively  minor  ways,  by  amendment  in 
1884,  1898,  and  1904. 

Ordinance  15,  Approved  April  11,  1797. 

An  ordinance  to  prevent  and  remove  nuisances  in  the  city  of  Baltimore, 
and  within  the  precincts  thereof,  and  to  provide  an  uniform  mode  for  clean¬ 
ing  the  streets,  lanes,  and  alleys  within  the  said  city. 

“  Be  it  enacted  and  ordained  by  the  Mayor  and  City  Council  of  Baltimore,  That  the 
inhabitants  and  occupiers  of  houses  and  lots,  and  sextons,  porters  or  other  keepers  of 
churches,  meeting-houses  or  other  public  buildings,  or  burying  grounds,  fronting  the 
paved  streets,  lanes  or  alleys  within  the  said  city,  shall  rake  and  sweep  into  the  cart¬ 
way,  the  dirt,  soil,  or  filth  to  be  found  on  the  brick  pavements,  foot-ways  and  gutters 
before  their  respective  houses,  lots,  dwellings  or  public  buildings,  or  cause  the  same  to 
be  done  once  in  every  week,  that  is  to  say  on  every  Friday,  by  ten  o’clock  in  the  fore¬ 
noon  (when  the  snow  or  ice  on  the  same  does  not  prevent)  that  it  may  be  removed 
as  is  hereinafter  provided,  under  the  penalty  of  any  sum  not  exceeding  one  dollar  for 
every  neglect  or  refusal,  for  the  use  of  the  city. 

“  And  be  it  enacted  and  ordained,  That  no  person  or  persons  whomsoever  shall  cast 
or  lay,  or  cause  to  be  cast  or  laid,  any  oyster  shells,  shavings,  ashes,  dirt  or  stable 
manure  on  any  of  the  streets,  lanes  or  alleys  of  the  said  city  (unless  the  same  be 
placed  or  laid  in  front  of  his,  her  or  their  lot,  and  removed  within  two  hours)  under 
the  penalty  of  two  dollars  for  every  such  offence,  for  the  use  of  the  city. 

“  And  be  it  enacted  and  ordained,  That  no  person  shall  cast,  place  or  throw  down  any 
rubbish,  dirt  or  materials  for  building  in  any  public  street,  lane  or  alley  of  the  said  city, 
save  only  in  such  parts  and  places  as  shall  be  appointed  and  agreed  on  by  the  persons 
duly  authorized  therefor  under  the  penalty  of  one  dollar,  for  the  use  of  the  city,  for 
every  two  hours  after  notice  to  remove  the  same.  Provided,  that  nothing  in  this  or¬ 
dinance  shall  be  construed  to  extend  to  any  person  or  persons  employed  in  building  or 
repairing  any  house,  houses  or  tenements,  so  far  as  shall  relate  to  materials  necessarily 
used  in  making  such  building  or  repairs;  but  the  said  person  or  persons  engaged  as 
aforesaid,  may  use  and  occupy  one-third  part  in  width  of  any  street,  lane  or  alley,  clear 
of  the  foot-way  in  front  of  any  lot  on  which  such  building  is  erecting,  or  repair  making, 
until  the  same  shall  be  covered  in,  and  twenty  days  thereafter,  and  no  longer,  nor  to 
any  person  or  persons  engaged  in  plastering  his,  her  or  their  house  or  houses,  but  such 
person  or  persons  shall  have  a  right  to  use  and  occupy  with  plastering,  mortar  or  other 
materials  necessary  therefor,  one  third  of  any  street,  lane  or  alley  in  front  of  his,  her  or 
their  lot  or  lots,  sixty  days,  and  no  longer,  without  the  permission  of  the  City  Com¬ 
missioners,  under  the  penalty  of  one  dollar  for  every  two  hours,  for  the  use  of  the 
city;  nor  shall  the  provisions  of  this  ordinance  extend  to  any  person  or  persons  dropping 
fire  wood  or  stone  coal  at  his,  her  or  their  door,  provided  the  foot-way  be  not  incom¬ 
moded  therewith,  or  by  the  sawing  or  cutting  of  said  wood ;  and  the  said  fire  wood  or 
stone  coal  be  removed  within  two  days  after  the  same  shall  be  dropped  as  aforesaid, 
under  the  penalty  of  one  dollar  for  every  day  thereafter,  for  the  use  of  the  city. 

“  And  be  it  enacted  and  ordained,  That  if  any  person  or  persons  whomsoever,  shall 
set  or  place  any  goods,  wares  or  merchandise,  by  way  of  exposing  them  to  sale,  on  or 
over  the  brick  or  stone  pavement,  in  any  public  street,  lane,  or  alley  in  this  city,  to 
project  more  than  twelve  inches  from  the  wall  of  his,  her  or  their  house  or  store,  every 
such  person  shall  pay  a  fine  of  one  dollar,  for  the  use  of  the  city:  Provided,  that  this 


64 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


clause  shall  not  extend  to,  or  interfere  with  any  regulation  in  the  ordinance  concern¬ 
ing  the  markets,  nor  extend  to  goods  sold  at  public  auction. 

“  And  be  it  enacted  and  ordained,  that  any  person  who  shall  place  or  pile  any  empty 
boxes,  barrels,  hogsheads  or  other  conveniency,  capable  of  containing  goods  or  mer¬ 
chandise,  or  that  may  have  contained  goods  or  merchandise,  in  any  part  of  the  streets, 
lanes  or  alleys  of  this  city  (except  as  is  before  excepted)  and  shall  not  remove  them 
from  the  same  within  four  hours  after  they  shall  have  so  been  placed  or  piled  there, 
every  such  person  shall  pay  a  fine  of  one  dollar  for  every  four  hours  the  same  shall 
thereafter  be  suffered  so  to  remain,  for  the  use  of  the  city. 

“  And  be  it  enacted  and  ordained,  That  if  any  tanner,  currier,  distiller,  brewer,  soap 
boiler,  tallow  chandler,  hatter,  dyer,  glue  boiler,  or  any  other  person  within  the  said 
city,  shall  discharge  any  foul  or  nauseous  liquor,  or  offal,  from  any  still-house,  workshop, 
or  yard,  so  that  such  liquor  or  offal  shall  pass  into  or  along  any  of  the  streets,  lanes  or 
alleys  of  the  said  city;  or  if  any  soap  boiler  or  tallow  chandler  shall  keep,  collect  or 
use,  or  cause  to  be  kept,  collected  or  used  in  any  part  of  the  said  city,  any  stale,  putrid 
or  stinking  fat,  grease  or  other  offensive  matter;  or  if  any  butcher  shall  keep  at  or  near 
his  slaughter  house,  any  garbage  or  filth  whatsoever,  so  as  to  annoy  any  neighbor,  or 
any  person  whomsoever,  he,  she  or  they  shall  forfeit  and  pay,  for  every  such  offence, 
the  sum  of  five  dollars,  and  shall  also  forfeit  and  pay  the  like  sum  for  every  day  the 
same  shall  be  suffered  so  to  remain,  for  the  use  of  the  city. 

“  And  be  it  enacted  and  ordained,  That  if  any  person  or  persons  having  a  hog  or 
hogs  within  their  enclosures  in  sties,  shall  keep  the  same  in  such  manner  that  the  stench 
and  filth  thereof  shall  become  offensive  to,  and  annoy  any  neighbor  or  person  whom¬ 
soever,  the  person  or  persons  so  keeping  his  or  their  hog  or  hogs  as  aforesaid,  shall 
forfeit  and  pay  for  every  such  offence,  one  dollar,  and  shall  also  forfeit  and  pay  the 
like  sum  for  every  day  the  same  shall  be  suffered  so  to  continue,  for  the  use  of  the 
city. 

“  And  be  it  enacted  and  ordained,  That  no  person  or  persons  whomsoever,  shall  cast, 
carry,  draw  out  or  suffer  to  lay  any  dead  horse  or  other  dead  carcase,  or  any  excrement 
or  filth  from  vaults,  privies  or  necessary  houses  in  any  part  of  the  said  city,  precincts 
or  harbor  of  Baltimore;  any  person  or  persons  offending  herein,  shall  forfeit  and  pay 
five  dollars  for  every  such  offence,  together  with  the  expense  of  removing  the  same, 
for  the  use  of  the  city. 

“  And  be  it  enacted  and  ordained,  That  the  city  commissioners  shall  on  the  Friday  or 
Saturday  of  every  week,  have  the  dirt  and  filth  found  on  any  of  the  paved  streets, 
lanes  or  alleys  of  the  said  city,  removed  therefrom,  and  deposited  in  such  place  or 
places  as  may  for  that  purpose  be  by  them  provided;  which  dirt  or  filth  shall  after¬ 
wards  be  disposed  of  in  such  manner  and  upon  such  terms  as  the  said  Commissioners 
shall  from  time  to  time  direct  and  appoint:  Provided,  nevertheless,  that  the  said  com¬ 
missioners  may  permit  any  person  or  persons  to  collect  and  carry  away  the  said  dirt  and 
filth,  or  may  contract  with  any  person  or  persons  for  the  removal  of  the  same,  or  any 
part  thereof,  so  that  the  same  be  removed  on  the  Friday  or  Saturday  of  each  week  as 
aforesaid,  under  the  penalty  of  one  dollar,  for  the  use  of  the  city,  for  each  and  every 
square  of  the  said  city  not  cleaned  as  aforesaid. 

“  And  be  it  enacted  and  ordained,  That  every  person  or  persons  possessing  a  lot  or 
lots,  wrhich  from  their  low  and  sunken  situations  are  liable  to  retain  tide  or  rain  water, 
or  on  which  cellars  or  foundations  for  buildings  may  be  dug,  and  no  tenement  erected 
over  the  same,  shall,  during  the  months  of  June,  July,  August,  September,  and  October, 
preserve  and  keep  the  said  lots,  cellars  and  foundations  dry  and  free  from  stagnant  or 
putrid  waters  and  other  filth;  any  person  or  persons  offending  herein,  shall  forfeit  and 
pay  five  dollars,  for  the  use  of  the  city,  for  every  week  he,  she  or  they  shall  suffer  such 
stagnant  or  putrid  water  or  other  filth  to  remain  thereon.  And  if  the  said  owner  or 
owners  shall,  notwithstanding  the  above  provision,  neglect  to  remove  such  stagnant  or 
putrid  water  or  other  filth,  the  city  commissioners  may  employ  such  person  or  persons 
as  they  may  think  proper,  and  upon  such  terms  as  to  them  may  seem  reasonable  and 
just,  to  remove  from  the  said  lot  or  lots,  cellars  or  foundations,  the  said  filth  or  stag¬ 
nant  or  putrid  water,  which  said  expense  shall  be  considered  as  a  further  fine  for  not 
complying  with  the  provisions  of  this  clause,  and  shall  be  collected  accordingly. 

“  And  be  it  enacted  and  ordained.  That  every  person  or  persons  possessing  a  tenement 
or  tenements,  warehouse  or  warehouses  on  any  part  or  parts  of  the  made  ground  of 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  G5 


said  city,  under  which  a  cellar  is  or  may  be  dug,  or  vacant  space  left,  shall,  during  the 
months  of  June,  July,  August,  September,  and  October,  keep  the  same  dry  and  clear 
of  stagnant  water,  mud  or  filth,  and  shall  at  least  once  in  every  week,  empty  and 
clear  out  any  stagnant  water,  mud,  or  filth  from  the  said  cellar  or  empty  space  left  as 
aforesaid ;  any  person  or  persons  offending  herein,  shall  forfeit  and  pay  for  every  of¬ 
fence  five  dollars,  for  the  use  of  the  city. 

“  And  be  it  enacted  and  ordained,  That  the  owner  or  owners  of  any  cart,  wagon,  or 
other  carriage,  that  shall  or  may  be  employed  in  removing  or  carrying  off  any  of  the 
paved  streets,  lanes,  or  alleys  of  the  city,  any  sand,  loam,  gravel,  earth,  dirt,  manure, 
stone,  bricks,  or  coal,  shall  have  and  keep  the  same  in  such  tight  and  secure  condition 
so  that  such  sand,  loam,  gravel,  earth,  dirt,  manure,  stone,  bricks  or  coal,  be  not  scat¬ 
tered  or  suffered  to  fall  on  any  of  the  streets,  lanes  or  alleys  aforesaid,  under  the  penalty 
of  seventy-five  cents,  for  the  use  of  the  city. 

“  And  be  it  enacted  and  ordained,  that  if  any  person  or  persons  shall  willfuly  and 
needlessly  fire,  shoot,  or  discharge  any  gun,  pistol,  or  other  fire-arms,  or  make  any  bon¬ 
fire,  or  burn  any  combustible  matter  in  any  of  the  streets,  lanes  or  alleys  of  the  said 
City,  every  such  person  for  every  such  offense  shall  forfeit  and  pay  one  dollar  for  the 
use  of  the  City. 

“  And  whereas,  great  injury  may  arise  to  the  citizens  of  Baltimore  from  the  going 
at  large  of  hogs,  goats,  and  geese  therein: 

“  Be  it  enacted  and  ordained,  That  the  city  commissioners  shall  employ  one  or  more 
persons  to  seize  and  take  all  hogs,  goats,  and  geese  found  at  large  within  the  said  City, 
and  the  same  to  sell  and  dispose  of  at  public  sale,  for  the  use  of  the  City. 

“  And  be  it  enacted  and  ordained,  That  this  ordinance  shall  commence  and  be  in  force 
from  and  after  the  first  of  May  ensuing,  and  continue  until  the  first  day  of  January 
next,  and  until  the  end  of  the  next  session  of  the  corporation  that  shall  happen  there¬ 
after.” 

The  foregoing  ordinance  was  modified  and  expanded  from  time  to  time 
by  later  ordinances. 

The  character  of  the  modifications  and  the  dates  they  were  made  can  be 
most  clearly  presented  under  separate  activities,  all  of  which,  however,  fall 
under  two  general  headings,  sanitation  on  public  and  on  private  domains. 

SANITATION  ON  PUBLIC  DOMAINS. 

Street  cleaning. — In  1798,  occupiers  or  owners  of  houses  and  lots  on  paved 
streets,  lanes  and  alleys  were  required  to  clean  the  gutters  in  front  of  them 
once  daily,  Sundays  excepted,  before  10  a.  m.  The  same  year  the  city  began 
to  sell  street  refuse,  a  practice  which  was  continued  for  many  years.  The  office 
of  superintendent  of  street  cleaning  was  created  at  this  time,  and  in  one  form 
or  another  this  office  has  been  continued.  Street  cleaning,  previously  under  the 
city  commissioners,  was  transferred  to  the  board  of  health  from  1845  until 
1881,  when  a  separate  department  was  established  under  an  independent  com¬ 
missioner.  Except  for  a  few  years  after  1849,  when  the  cleaning  of  streets  was 
let  out  to  contractors,  this  work  was  done  by  employees  of  the  city. 

COLLECTION  AND  DISPOSAL  OF  GARBAGE. 

In  1821  the  superintendent  of  streets  was  required  to  collect  garbage  on 
Tuesdays,  Thursdays,  and  Saturdays  from  May  1  to  November  1,  and  in  1850 
watertight  and  covered  carts  were  provided  for  garbage  and  ash  removal,  and 
the  removal  of  offal  and  garbage  from  the  markets  was  undertaken.  In  1S77 
it  was  provided  by  law  that  all  garbage  and  other  like  refuse,  which  heretofore 
had  been  deposited  on  dumps  within  or  near  the  city  limits,  should  be  trans- 


66  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

ported  by  rail  or  water  at  least  6  miles  from  the  city  limits.  From  1904  until 
1919  garbage  so  removed  was  rendered  under  contract  at  a  point  on  the  bay 
well  beyond  the  city. 

NIGHT-SOIL  DISPOSAL. 

In  1880,  the  administrative  authorities  were  granted  power  to  enter  into 
contract  to  have  the  night-soil,  which  heretofore  had  been  deposited  on  dumps 
with  the  garbage,  transported  by  barges  to  proper  places  beyond  the  city.  As 
the  laws  relating  to  paving,  sewers,  and  water  supplies  have  to  do  much  more 
with  the  inauguration  than  with  the  regulation  of  these  services,  they  are 
omitted  here. 

SANITATION  ON  PRIVATE  DOMAINS. 

The  health  officer  or  the  commissioners  of  health  were  empowered  by  the 
ordinance  of  February  28,  1798,  to  order  any  damaged  hides,  coffee,  or  other 
damaged  goods  found  within  the  city  to  be  removed  therefrom  to  a  distance  not 
exceeding  3  miles.  The  ordinance  of  March  20,  1801,  gave  authority  to  the 
commissioner  of  health  to  enter  all  lots,  grounds,  and  buildings  on  which 
nuisances  of  any  description  might  exist,  and  refusal  or  neglect  to  abate  nui¬ 
sances  on  the  order  of  a  commissioner  of  health  was  made  punishable  by  a  fine 
of  $20.  This  power  was  amplified  by  the  ordinance  of  March  22,  1803,  to  in¬ 
clude  cellars  and  docks.  According  to  the  ordinance  of  February  10,  1820,  each 
commissioner  of  health  was  required  to  inspect,  at  least  once  every  two  weeks 
between  the  first  day  of  March  and  the  first  day  of  November,  all  cellars,  yards, 
lumber-yards,  lots,  and  docks  (in  addition  to  streets,  lanes,  and  alleys)  within 
his  district  and  to  remove  or  cause  to  be  removed  all  nuisances. 

PRIVIES,  CESSPOOLS,  AND  NIGHT-SOIL. 

The  ordinance  of  February  28,  1798,  empowered  the  commissioners  of  health 
to  appoint,  license,  or  remove  all  night-soil  men. 

By  the  ordinance  of  March  18,  1811,  it  was  made  unlawful  to  erect  a  privy 
or  other  building  over  a  wharf  or  stone  wall  on  Jones  Falls,  within  the  limits 
of  the  city,  which  would  discharge  into  the  falls  except  by  means  of  a  sewer 
emptying  below  the  high-water  mark. 

According  to  the  ordinance  of  March  18,  1817,  no  well  or  hole  could  be 
sunk  for  the  purpose  of  erecting  a  privy  over  it  or  of  depositing  any  odure  or 
other  filth  therein  or  of  depositing  any  odure  in  or  upon  the  surface  of  the 
earth  (except  in  privies  already  erected)  in  that  part  of  the  city  bounded  on 
the  north  by  Franklin  Street,  on  the  west  by  North  Charles  Street,  on  the  south 
by  New  Church  Street,  and  on  the  east  by  North  Calvert  Street. 

The  ordinance  of  March  9,  1820,  required  that  all  dead  animals,  including 
fish,  and  all  excrement  or  filth  from  vaults  and  privies,  should  be  so  covered 
with  earth  on  removal  as  to  prevent  any  noxious  effluvia  arising  from  them. 
It  was  also  unlawful  to  discharge  into  any  street,  lane,  or  alley  of  the  city  any 
foul  or  nauseous  liquors,  or  any  other  offensive  matter. 

It  was  provided  in  the  ordinance  of  March  27,  1820,  that  the  vault  or  well 
of  every  privy  which  should  be  erected  within  certain  limits  (apparently  about 
a  block)  on  each  side  of  the  Eastern  Spring  and  the  Western  Spring  should  be 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  67 

built  and  floored  with  sound  and  well-burned  brick,  at  least  1  foot  thick  at  the 
bottom  and  not  less  than  9  inches  thick  for  the  walls,  and  set  in  with  a  cement 
impervious  to  water.  These  vaults  were  not  to  exceed  6  feet  in  depth  and  were 
to  be  well  puddled  with  clay  rammed  compactly  at  the  bottom  and  on  all  sides 
of  every  such  privy  at  least  1  foot  thick.  It  was  further  provided  that  every 
privy  heretofore  or  hereafter  to  be  erected,  all  being  within  the  aforesaid  limits, 
be  cleaned  out  at  least  once  every  year,  and  oftener  if  required,  by  the  com¬ 
missioners  of  health.  If  the  commissioners  of  health  found  any  privy  heretofore 
erected  within  the  limits  described  likely  to  injure  or  corrupt  the  waters  of 
the  springs,  they  were  to  order  the  owner  to  clean  it  out  and  rebuild  it. 

Through  the  ordinance  passed  in  November  1821,  it  was  ordered  that  all 
privies  kept  for  private  use  on  docks,  wharves,  or  made  ground  be  made  water¬ 
tight  and  sprinkled  weekly  with  lime  from  the  first  of  May  until  the  first  of 
November.  This  ordinance  further  provided  that  a  public  privy  be  constructed 
on  each  of  the  public  wharves  where  it  was  deemed  expedient  and  in  the  vicinity 
of  the  several  market-houses,  and  that  all  other  privies  hereafter  to  be  con¬ 
structed  within  the  limits  of  direct  taxation  were  to  be  made  water-tight.  No 
person  was  permitted  to  drain  a  privy  to  cover  its  contents,  but  the  contents 
were  to  be  cleaned  out  and  removed  without  the  limits  of  the  city. 

It  became  the  duty  of  the  board  of  health  by  the  passage  of  the  ordinance  of 
October  26,  1872,  to  cause  inspections  of  privies  to  be  made  between  the  first 
and  tenth  of  June  by  the  police,  who  were  required  to  report  those  in  a  state 
of  nuisance  which  were  found  full  or  likely  to  become  full  before  the  first  of 
October.  It  was  further  provided  that  the  emptying  and  removal  of  the  con¬ 
tents  of  privies  should  be  done  between  the  first  of  October  and  the  first  of 
June. 

The  ordinance  of  November  1,  1873,  empowered  the  board  of  health  to  permit 
any  person  to  clean  sinks  and  privy  vaults  during  the  day  time,  provided  the 
receptacle  was  air-tight  and  the  work  could  be  done  without  annoyance  to 
citizens. 

The  board  of  health  was  empowered  by  the  ordinance  of  June  17,  1886,  to 
clean,  privies  and  to  abate  other  nuisances  at  the  expense  of  the  owners,  agents, 
or  occupiers,  when  they  had  neglected  or  refused  to  do  so.  There  was  to  be 
no  cleaning  of  privies  between  the  first  of  June  and  the  first  of  October  unless 
it  was  deemed  necessary  for  the  health  and  comfort  of  the  neighborhood. 

On  October  23,  1891,  it  was  ordained  that  every  well  used  as  a  cesspool 
should  be  covered  with  stone  not  less  than  4  inches  thick  or  with  iron  not  less 
than  1  inch  thick,  should  be  at  least  6  feet  deep,  and  walled  up  with  brick  and 
stone,  and  should  be  well  and  satisfactorily  built.  When  a  well  was  to  be  used 
as  a  privy,  the  floor  was  to  be  covered  its  full  length  and  width  with  the  material 
and  thickness  as  above  stated.  In  all  cases  such  wells  and  privies  were  to  be 
water-tight. 

The  ordinance  of  February  26,  1906,  made  it  unlawful  hereafter  to  construct 
any  privy  well  to  be  used  in  connection  with  more  than  one  house. 

MEASURES  AGAINST  STANDING  WATER  AND  DECAYING  VEGETABLE 
MATERIAL  ON  LOW  GROUNDS,  WHARVES,  AND  DOCKS. 

It  was  made  unlawful  by  the  ordinance  approved  March  6,  1820,  to  fill  in  the 
wharves  and  low  grounds,  in  any  part  of  the  city,  with  any  kind  of  wood, 


68 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


shavings,  or  vegetable  matter.  It  was  further  provided  that  no  spars,  arks,  logs, 
or  timber,  with  any  bark  or  sap  on  them,  other  than  square  timber,  should  re¬ 
main  in  the  water  of  the  harbor  or  in  any  situation  within  200  yards  of  any 
dwelling  or  wharf  where  a  common  tide  could  reach  them,  without  the  written 
permission  of  the  board  of  health.  This  provision  extended  from  the  first  of 
June  until  the  first  of  November.  The  throwing  of  any  kind  of  animal, 
fruit,  or  vegetable  matter  into  the  basin  or  dock  or  into  Jones  Falls  was  for¬ 
bidden  during  the  same  period  of  time. 

The  ordinance  of  March  27,  1821,  required  that  owners  of  all  lumber,  ship, 
cooper,  and  wood  yards  and  saw  mills  on  low  or  made  ground  should,  at  the 
discretion  of  the  board  of  health,  cover  the  ground  with  a  sufficiency  of  fresh 
earth  and  lime  and  from  time  to  time  burn  their  vegetable  offals.  It  was  re¬ 
quired  that  all  wood-yards  for  the  deposit  or  sale  of  firewood  be  raised  above 
standing  water  and  the  wood  piled  in  such  a  way  as  to  permit  the  free  circula¬ 
tion  of  air.  The  board  of  health  was  authorized  to  compel  the  owner  or  owners 
of  any  vacant  lots  to  keep  them  clear  of  nuisances  and  to  grade  them  so  as  to 
prevent  any  water  from  remaining  upon  them. 

By  this  same  ordinance  the  board  of  health  was  required  to  order  the 
cleansing  of  the  heads  of  docks,  sewers,  and  tunnels,  and  the  deposits  of  sewers. 
All  wharves  where  wood  was  landed  were  to  be  scraped  as  often  as  the  board 
of  health  might  require  in  order  to  prevent  the  offals  of  the  wood  from  falling 
into  the  docks  or  basin.  This  offal,  with  the  deposits  from  the  sewers  and  the 
heads  of  docks,  was  to  be  disposed  of  as  manure.  This  ordinance  prohibited 
the  floating  of  square  timber  in  the  water  of  the  harbor. 

It  was  required  by  the  ordinance  of  November  1821,  that  not  less  than  3 
feet  of  water  be  obtained  at  the  lowest  common  tide  at  the  docks  and  wharves 
of  the  city  between  the  first  of  June  and  the  first  of  October.  The  board  of 
health  was  authorized  to  prohibit  all  offal  and  deposits  of  privies,  factories, 
distilleries,  butchers’  and  other  shops,  the  jail,  penitentiary,  and  other  foul 
premises  from  being  dumped  into  any  of  the  streams  of  water  or  public  sewers 
within  the  city  or  in  Jones  Falls,  and  all  private  sewers,  carrying  other  than 
clean  water,  from  entering  these  falls.  The  public  sewers  were  to  be  cleaned 
weekly  from  the  first  of  April  until  the  first  of  October. 

The  ordinance  of  March  8,  1822,  repealed  that  part  of  the  last  ordinance 
which  required  that  the  board  of  health  be  authorized  to  prohibit  all  offal  from 
being  deposited  in  the  waters  of  Jones  Falls. 

The  commissioners  of  health  were  empowered  by  an  ordinance  approved 
March  11,  1823,  to  drain  instead  of  fill  up  low  grounds,  when  in  their  opinion 
draining  would  answer  the  intended  purpose  and  where  the  ground  to  be 
drained  was  not  bounded  by  any  street,  lane,  or  alley. 

On  June  22,  1915,  the  following  ordinance  for  the  prevention  of  the  breeding 
of  mosquitoes  was  approved : 

“  1.  It  shall  be  unlawful  to  have,  cause,  maintain,  or  permit  within  the  municipality 
of  Baltimore,  any  collection  of  standing  or  flowing  water  in  which  mosquitoes  breed, 
or  are  likely  to  breed,  unless  such  collection  of  water  is  treated  so  as  to  effectually 
prevent  such  breeding. 

“  2.  The  collections  of  water  referred  to  in  section  1  of  this  ordinance  shall  be  held  to 
be  those  contained  in  ditches,  gutters,  rain  gutters  or  roof  gutters,  ponds,  pools,  ex¬ 
cavations,  holes,  depressions,  open  cesspools,  privy  vaults,  fountains,  cisterns,  tanks, 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  69 


shallow  wells,  barrels,  troughs  (except  horse  troughs  in  frequent  use),  urns,  cans,  boxes, 
bottles,  tubs,  buckets,  or  other  similar  containers. 

“  3.  The  methods  of  treatment  of  the  collections  of  water  specified  in  section  2  so  as 
to  prevent  breeding  of  mosquitoes  shall  be  any  one  or  more  of  the  following: 

“  (a)  Screening  with  wire  netting  of  at  least  16  meshes  to  the  inch  each  way,  or  any 
other  material  which  will  prevent  the  ingress  or  egress  of  mosquitoes. 

“  (6)  Complete  emptying  every  7  days,  or  at  shorter  periods,  of  unscreened  containers. 

“  (c)  Using  a  larvicide  approved  and  applied  under  the  direction  of  Dr.  Henry  R. 
Carter,  assistant  surgeon  general  of  the  United  States  Public  Health  Service,  or  any  one 
deputized  by  him  for  that  purpose. 

“  ( d )  Covering  completely  once  every  7  days  the  surface  of  the  water  with  kerosene, 
petroleum,  or  paraffine  oil  in  sufficient  quantities  to  remain  covered  at  least  12  hours 
each  time. 

“  ( e )  Cleaning  and  keeping  sufficiently  free  of  vegetable  growth  and  other  obstruc¬ 
tions,  and  stocking  with  mosquito-destroying  fish;  absence  of  half-grown  or  large  mos¬ 
quito  larva  to  be  evidence  of  compliance  with  this  measure. 

“  (/)  Filling  or  draining  to  the  satisfaction  of  the  commissioner  of  street  cleaning  ol 
Baltimore  City,  or  any  one  deputized  by  him  for  that  purpose. 

“  ( g )  The  removal  of  tin  cans,  tin  boxes,  broken  or  empty  bottles,  and  similar  articles 
likely  to  hold  water,  at  least  once  every  7  days.  If  not  removed  they  must  be  so  com¬ 
pletely  destroyed  as  not  to  be  able  to  hold  water. 

“  4.  Any  person  who  shall  violate  any  provision  of  this  ordinance  shall  on  each 
conviction  be  subject  to  a  penalty  of  not  less  than  one  nor  more  than  ten  dollars,  to 
be  collected  as  other  penalties  imposed  by  ordinance,  and  the  payment  of  any  costs 
incurred  under  paragraph  5  hereof.” 


CELLARS. 

The  board  of  health  was  required  by  the  ordinance  of  March  27,  1821,  to 
see  that  all  cellars  on  low  or  made  ground  were  filled  up  or  otherwise  im¬ 
proved  at  the  expense  of  their  owners. 

In  November  1821,  an  ordinance  was  passed  requiring  that  all  cellars  and 
other  confined  surfaces  on  low  or  made  ground  “  and  where  yellow  fever  is 
liable  to  prevail  ”  be  filled  so  as  to  preserve  them  as  dry  as  possible ;  that  they 
be  kept  clean  and  well  aired  and  sprinkled  from  time  to  time  with  fresh  earth 
and  lime;  and  that  all  cellars  on  made  ground  be  ventilated  by  properly  con¬ 
structed  flues  and  by  leaving  a  space  not  filled  in,  or  by  raising  the  floor,  or 
both,  so  as  to  admit  cleaning  them. 

It  was  provided  by  the  ordinance  of  March  11,  1823,  that  all  cellars  and 
vacancies  under  stores  or  warehouses  on  made  ground  should,  when  it  was 
deemed  necessary  by  the  board  of  health,  be  filled  by  sound  materials  and 
paved  with  hard  bricks  or  stone;  that  the  lots  thereunto  appertaining  should 
be  filled  up  above  the  level  of  the  street;  and  that  all  frame  buildings  below 
the  level  of  the  brick  pavement  or  the  street  should  be  raised  up  and  under¬ 
pinned  with  brick  or  stone. 

MANUFACTORIES  INJURIOUS  AND  DANGEROUS  TO  HEALTH. 

Since  section  6  of  Ordinance  15,  1797,  certain  provisions  in  regard  to  these 
manufactories  have  been  carried  for  many  years  in  the  codes.  Some  of  these 
provisions  date  from  early  times.  In  general  they  apply  to  the  manufacture  of 
substances  at  or  during  the  preparation  of  which  offensive  odors  are  given  off, 
such  as  the  preparation  of  roofing  materials,  the  manufacture  of  varnish,  the 
grinding  of  bones,  the  distillation  of  turpentine,  the  manufacture  of  soap  and 


70  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

candles,  and  the  manufacture  of  various  acids,  bleaching  substances,  pigments 
of  lead,  in  the  process  of  which  it  is  necessary  to  bum  horns,  blood,  bones, 
etc.  All  these  activities  were  allowed,  but  under  restrictions,  usually  not  within 
a  certain  number  of  feet  of  dwellings  and  by  permission. 

Under  ordinance  of  April  7,  187.1,  it  was  provided  that  no  slaughter  or  hide 
house  should  afterwards  be  erected  within  the  city  limits. 

According  to  the  ordinance  of  May  25,  1893,  no  persons  were  henceforth  to 
be  allowed  to  erect  or  establish  within  the  city  limits  any  poudrette  works, 
glue  factories,  or  establishments  for  the  purpose  of  rendering  grease,  dead  ani¬ 
mals,  or  animal  offal,  or  stock  yards  for  receiving,  feeding,  and  offering  for 
sale  live  stock. 

GARBAGE. 

By  the  ordinance  of  November  1821,  it  was  required  that  household  filth 
of  all  premises  be  put  out  in  the  streets,  lanes,  or  alleys  adjoining,  every  Tues¬ 
day,  Thursday,  and  Saturday  of  each  week,  from  the  first  of  May  to  the  first 
of  November,  before  8  o’clock  in  the  morning,  in  order  that  it  might  be  removed 
by  the  superintendents  of  the  streets. 

Housekeepers  were  required  by  the  ordinance  of  April  2,  1853,  to  place  all 
offal,  coal  ashes,  or  dirt  which  might  engender  disease,  in  a  box  or  other  vessel 
convenient  of  access  to  the  garbage  collectors. 

The  ordinance  of  June  17,  1886,  required  householders  to  provide  suitable 
containers  for  garbage  and  offal,  and  they  were  forbidden  to  throw  such  materials 
into  any  street,  market,  or  other  public  place. 

Occupants  of  dwelling-houses,  proprietors  of  boarding-houses,  commission 
houses,  hotels,  restaurants,  and  other  places  where  garbage  accumulates,  and 
owners,  agents,  and  occupants  of  apartment  or  tenement  houses  were  required 
by  the  ordinance  of  May  20,  1919,  to  provide  a  sufficient  number  of  receptacles 
to  contain  all  garbage  which  accumulated  on  the  premises  during  the  usual  in¬ 
terval  between  the  collections  of  garbage.  These  receptacles  were  to  be  of  metal, 
water-tight,  and  provided  with  a  tight-fitting  metal  cover,  with  a  handle ;  they 
were  to  contain  not  less  than  3  nor  more  than  10  gallons  and  be  so  constructed 
that  the  garbage  could  be  easily  removed;  they  were  to  be  easily  accessible  to 
the  garbage  collector;  and  they  were  to  be  kept  covered  continuously  except 
when  being  filled  or  emptied.  It  was  declared  unlawful  to  include  with  the 
garbage  any  ashes,  rubbish,  or  trash.  It  was  further  ordained  that  no  dead 
animal,  offal,  garbage,  or  putrescible  matter  of  any  sort  was  to  be  placed  or 
thrown  on  any  public  highway  or  in  any  public  sewer,  and  that  nothing  likely 
to  produce  nauseating,  vile,  or  offensive  smoke  or  vapors  was  to  be  burned. 

HABITATIONS. 

The  ordinance  of  June  5,  1871,  provided  for  an  inspector  of  buildings.  He 
was  to  supervise  the  construction  and  repair  of  city  buildings,  look  after  the 
condition  of  such  private  buildings  as  might  be  dangerous  to  persons  and 
property,  and  control  the  installation  and  building  of  boilers  and  steam-engines 
and  the  placing  of  sheds,  bay  windows,  telegraph  poles,  signs,  awnings,  and 
frame  buildings. 

The  ordinance  of  June  4,  1886,  regulated  dwellings,  tenements,  and  lodging- 
houses  as  follows:  Every  house  or  building  used,  occupied,  leased,  or  rented 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  71 

as  a  dwelling,  tenement,  or  lodging-house  was  to  have  in  every  sleeping-room 
which  did  not  communicate  directly  with  the  external  air  a  ventilating  or  tran¬ 
som  window  with  an  opening  or  area  of  3  square  feet  above  the  door  leading  into 
the  adjoining  room,  provided  the  adjoining  room  communicated  with  the  ex¬ 
ternal  air,  and  also  a  ventilating  or  transom  window  of  the  same  opening  or 
area  communicating  with  the  entry  or  hall  of  the  house.  Where  this  was  im¬ 
practicable,  due  to  the  situation  of  the  room,  the  latter  ventilating  or  transom 
window  was  to  communicate  with  an  adjoining  room  which  communicated  with 
the  entry  or  hall.  Every  such  house  or  building  was  to  have  in  the  roof  at  the 
top  of  the  hall  an  adequate  and  proper  ventilator,  of  a  form  approved  by  the 
inspector  of  buildings  and  the  board  of  health. 

The  roof  of  every  such  house  was  to  be  kept  in  good  repair  so  that  it  would 
not  leak,  and  all  rain-water  was  to  be  so  drained  therefrom  as  to  prevent  its 
dripping  on  the  ground  or  causing  dampness  in  the  walls,  yards,  or  areas. 

These  houses  were  to  be  provided  with  good  and  sufficient  privies  or  water- 
closets,  not  less  than  1  to  every  20  occupants,  which  could  be  used  in  common  by 
occupants  of  any  two  or  more  houses,  provided  the  access  was  convenient  and 
direct  and  the  number  of  occupants  in  the  houses  did  not  exceed  the  above  pro¬ 
portion.  No  privy  well  was  to  be  allowed  in  or  under  or  connected  with  any 
such  house  except  when  unavoidable,  in  which  case  it  was  to  be  constructed  in 
such  a  situation  and  manner  as  the  board  of  health  might  direct.  In  all  cases 
it  was  to  be  water-tight  and  so  constructed  that  no  offensive  smell  or  gases  could 
escape.  The  yard  or  area  was  to  be  so  graded  that  all  water  from  the  roof  or 
otherwise  could  flow  freely  from  all  parts  of  it  into  the  street  gutter. 

The  sleeping  or  resident  portion  of  any  building  was  to  be  at  least  3  feet  of 
its  height  and  space  above  the  level  of  the  sidewalk  or  curbstone  of  any  ad¬ 
jacent  street.  The  floors  were  not  to  be  damp  by  water  from  the  ground,  nor 
were  the  rooms  to  be  impregnated  or  penetrated  by  any  offensive  gas,  smell, 
or  exhalation  prejudicial  to  health.  Overcrowding  was  forbidden,  but  no 
figures  were  given.  Every  dwelling,  tenement,  and  lodging  house  was  to  be 
kept  clean  and  free  from  any  accumulation  of  filth,  garbage,  and  other  matter 
in  or  on  them  or  in  the  yards,  courts,  areas,  passages,  or  alleys  connected  with 
or  belonging  to  them.  The  owner  or  lessee  of  any  dwelling,  tenement,  or  lodging 
house  was  required  to  cleanse  thoroughly  all  the  rooms,  passages,  stairs,  floors, 
windows,  doors,  walks,  ceilings,  and  privies  to  the  satisfaction  of  the  board 
of  health,  as  often  as  it  was  deemed  necessary,  and  was  to  whitewash  the  walls 
and  ceilings  thereof  at  least  once  a  year. 

Secure  foundations  and  construction  of  buildings  were  provided  for  in  the 
ordinance  of  October  23,  1891,  which  dealt  at  length  with  the  thickness  of  walls 
and  the  strength  of  structure  for  buildings  of  various  heights  and  the  details 
of  structure  in  regard  to  fire  prevention. 

In  1908,  all  the  previous  building  laws  were  repealed  and  for  them  was 
substituted  a  comprehensive  building  code,  which  goes  into  great  detail  con¬ 
cerning  structure,  space,  and  position  of  private  and  public  buildings. 

This  code  prescribes  that  no  tenement  or  apartment  houses  may  be  built  on 
any  lot  facing  a  street  less  than  40  feet  wide;  that  there  must  be  a  space 
of  from  10  to  25  feet,  according  to  the  number  of  stories,  between  such  houses 
and  other  buildings  within  a  block;  that  they  are  not  to  cover  more  than  80 


72  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

per  cent  of  a  lot  bounded  by  two  intersecting  streets  and  must  have  in  the  rear, 
when  erected  on  an  interior  lot,  a  yard  extending  the  entire  width  of  the  lot ; 
that  the  height  must  not  exceed  the  width  of  the  widest  street  upon  which  they 
stand  by  more  than  one-half;  and  that  the  basement  story  must  not  be  less 
than  8  feet  in  the  clear  and  all  other  stories  not  less  than  9  feet  in  the  clear. 
In  tenement  and  apartment  houses,  every  court,  entirely  inclosed  by  build¬ 
ings,  onto  which  windows  open  from  living  rooms,  is  to  have  minimum  dimen¬ 
sions  both  in  area  and  width,  varying  from  100  square  feet  in  area  and  6  feet 
in  width  in  two-story  buildings  to  1,600  square  feet  in  area  and  24  feet  in 
width  in  ten-story  buildings.  Suitable  provisions  are  made  for  passages,  stair¬ 
ways,  and  ventilating  shafts  for  toilets,  kitchens,  pantries,  cellars,  basements, 
and  the  like;  for  the  size  of  apartments  and  rooms;  and  for  access  to  stair¬ 
ways  and  fire  escapes.  Every  one-family  apartment  is  to  contain  not  less  than 
two  rooms,  one  of  which  is  not  to  be  less  than  120  square  feet  in  floor  area,  and 
neither  of  which  is  to  be  less  than  70  square  feet  in  area.  There  shall  not  be 
less  than  400  cubic  feet  of  air-space  for  every  person  over  12  years  of  age  and 
200  cubic  feet  of  air-space  for  every  child  under  12  years  of  age  occupying  a 
room.  Every  apartment  must  have  a  sink  with  running  water  and  a  separate 
water-closet  in  a  separate  apartment  within  each  apartment.  On  every  floor 
of  a  tenement  or  apartment  house  providing  apartments  for  families,  there 
must  not  be  less  than  one  water-closet  for  each  family.  Hallways  must  be 
ventilated  by  skylights  in  the  top  story  of  apartments  and  by  windows.  All 
living  rooms,  including  all  rooms  except  bath-rooms,  water-closets,  and  pantries, 
are  to  be  lighted  and  ventilated  by  windows  opening  directly  into  the  street, 
alley,  court,  or  yard.  The  total  area  of  such  windows  must  equal  one-tenth  of 
the  floor  area  of  the  room,  and  every  room  must  have  at  least  one  window  not 
less  than  12  square  feet  in  area,  with  its  top  not  less  than  7  feet  6  inches  above 
the  floor.  All  bath-rooms,  water-closets,  and  pantries  must  be  lighted  and  ven¬ 
tilated  by  windows  not  less  than  3  square  feet  in  area  and  opening  directly  onto 
a  street,  alley,  open  court,  or  shaft.  These  windows  are  to  be  so  constructed  that 
the  top  halves  of  the  windows  may  be  entirely  opened  for  the  passage  of  out¬ 
side  air.  No  paper  shall  be  put  on  the  walls  of  a  room  until  all  former  wall  paper 
has  been  removed  and  the  walls  and  ceilings  thoroughly  cleaned.  Cellar  walls 
and  ceilings  must  be  thoroughly  whitewashed  or  painted  a  light  color  at  least 
once  a  year.  Every  apartment  is  to  have  at  least  one  chimney-flue  for  stove 
connections.  The  alterations,  repairs,  and  changing  of  other  buildings  into  tene¬ 
ment  or  apartment  houses  may  only  be  made  under  the  supervision  of  the 
inspector  of  buildings.  Tenement  and  apartment  houses  erected  prior  to  the 
date  of  this  code  were  ordered  to  be  changed  partially  or  totally  to  conform 
with  all  the  provisions  concerning  tenement  or  apartment  houses. 

Provisions  in  regard  to  lodging-houses  and  hotels  apply  to  those  erected  after 
the  date  of  the  code.  These  provisions  follow  very  closely  those  which  govern 
tenement  and  apartment  houses,  but  they  are  somewhat  more  exacting.  Every 
sleeping-room  in  a  hotel  or  lodging-house  must  have  not  less  than  700  cubic  feet 
of  air-space  for  every  person,  every  bedroom  is  to  be  lighted  and  ventilated  by 
a  window  or  windows,  opening  directly  upon  a  street,  alley,  court,  or  yard, 
and  at  least  one  window  in  every  such  room  is  to  be  not  less  than  12  square 
feet  in  area.  Every  lodging-house  which  accommodates  more  than  20  persons 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  73 

must  have  one  isolation  room  on  the  top  floor  with  not  less  than  1,000  cubic 
feet  of  air-space  and  with  a  separate  sealed  olf  water-closet.  Ventilation  is  to 
be  by  means  of  a  skylight,  and  the  walls,  roof,  and  ceiling  are  to  be  water-proof. 
The  bath-rooms  must  have  windows  of  an  area  not  less  than  one-eighth  of  the 
floor  area  in  the  isolation  room  and  not  less  than  3  square  feet  in  the  water- 
closet.  These  windows  must  open  on  a  street,  alley,  or  yard. 

All  buildings  must  have  suitable  window  areas,  and  they  shall  be  so  placed 
upon  their  respective  sites  and  their  window  construction  shall  be  so  arranged 
that  the  proper  amount  of  light  and  ventilation  may  be  secured  in  all  parts 
and  subdivisions  of  such  buildings  and  for  all  the  purposes  of  their  occupation, 
all  as  may  be  determined  by  the  inspector  of  buildings. 

In  two-story  houses,  the  interior  room  or  rooms  on  the  second  floor  not  open 
to  the  air  and  light  by  direct  access  to  areas  or  courts  are  to  be  provided  with 
skylights,  each  of  an  area  not  less  than  5  per  cent  of  the  floor  area  of  the  room 
in  which  the  skylight  is  located  and  arranged  to  provide  proper  ventilation  as 
well  as  light. 

The  inspector  of  buildings  must  receive  applications,  examine  plans,  and 
grant  permits  for  the  erection,  construction,  alteration,  repair,  and  removal  of 
buildings.  He  must  inspect  or  cause  to  be  inspected  all  works  of  construction,  all 
walls,  dangerous  buildings,  and  all  buildings,  public  and  private,  and  all  por¬ 
tions  and  parts  thereof.  He  must  determine  the  application  and  interpreta¬ 
tion  of  the  code  and  pass  upon  every  question  relating  to  the  method  of  con¬ 
struction  or  materials  used  in  the  erection,  repair,  or  alteration  of  buildings. 
For  these  purposes  he  may  make  rules  and  regulations. 

PLUMBING. 

The  ordinance  of  October  22,  1883,  granted  the  power  to  the  commissioner  of 
health  with  the  mayor  to  appoint  annually  an  inspector  of  plumbing  for 
sanitary  purposes,  who  shall  be  under  the  direction  and  supervision  of  the 
board  of  health.  The  inspector  must  be  a  practical  plumber  and  not  interested 
either  directly  or  indirectly  during  the  holding  of  his  office  in  the  business  of 
plumbing  or  furnishing  plumbing  materials.  This  ordinance  provided  that  no 
pipe  then  used  or  thereafter  to  be  used  to  drain  any  matter,  liquid  or  solid,  from 
any  building  used  for  habitation  or  occupancy  by  man,  into  any  well  or  sink 
used  for  the  reception  of  any  substance  except  pure  water,  or  into  any  public 
sewer,  or  into  any  stream,  or  into  any  harbor,  should  be  put  up,  constructed, 
altered,  or  repaired  without  first  obtaining  a  permit  therefor  from  the  board 
of  health.  Construction  so  authorized  could  not  be  undertaken  at  a  date  earlier 
than  that  named  in  the  application  for  such  permit,  and  all  such  plumbing 
work,  as  above  referred  to,  was  to  be  done  subject  to  the  supervision  of  the 
inspector  of  plumbing  and  in  strict  conformity  to  such  orders  and  directions  as 
might  be  prescribed  by  the  inspector  with  the  approval  of  the  board  of  health. 
Whenever  such  work  was  completed  in  a  manner  satisfactory  to  the  inspector,  he 
was  required  to  give  to  the  owner  or  owners  of  the  premises  a  certificate  of 
inspection  and  approval. 

In  1898,  the  commissioner  of  health  published  a  pamphlet  of  rules  and  regu¬ 
lations  comprising  44  sections,  dealing  with  plumbing  and  plumbing  inspec¬ 
tion  and  based  upon  the  above  law.  While  these  regulations  for  the  most  part 


74 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


have  to  do  with  the  administrative  details  in  the  carrying  out  of  the  ordinances, 
they  are  important  from  the  standpoint  of  construction  in  that  they  give 
definite  instructions  regarding  the  size  and  laying  of  pipes,  the  character  of 
joints,  and  the  like.  They  make  obligatory  the  use  of  traps  and  fresh-air  inlets 
and  prescribe  their  situation.  All  these  provisions  conform  in  general  with 
the  accepted  usages  of  that  date.  They  forbade  the  construction  of  water- 
closets  in  sleeping-rooms,  or  in  any  apartment  or  vault  not  in  direct  communi¬ 
cation  with  the  outside  air  by  means  of  a  window  or  air-shaft  having  an  area 
of  at  least  4  square  feet  for  the  admission  of  fresh  air  and  light.  For  water- 
closets  situated  outside  of  buildings,  the  use  of  straight  non-absorbent  hoppers 
without  flush-tanks  was  permitted.  The  connection  of  waste  pipes  from  bath¬ 
tubs,  wash-stands,  and  sinks  with  the  trap  of  a  water-closet  was  forbidden. 
Except  as  mentioned,  all  water-closets  were  required  to  have  separate  flush  tanks 
holding  at  least  4  gallons  of  water.  The  use  of  long,  straight  hoppers,  or  offset 
hoppers,  or  pan  and  plunge  closets,  was  forbidden  in  any  building.  Water- 
closets  and  urinals  could  not  be  connected  directly  with  or  flushed  from  water- 
supply  pipes,  but  they  must  be  flushed  from  separate  systems  on  every  floor, 
the  water  of  which  is  used  for  no  other  purpose.  Safes  and  refrigerators  are  to 
be  drained  by  special  pipes  not  connected  with  the  house  drain  or  main  sewer. 
Wooden  laundry  wash  trays,  or  kitchen  or  other  sinks  were  prohibited  inside 
buildings. 

In  the  building  code  of  1908,  there  is  a  section  on  plumbing  comprising  23 
pages.  In  this  code,  all  plumbing  and  drainage  are  placed  under  the  supervision 
of  the  commissioner  of  health,  but  he  is  required  to  furnish  the  inspector  of 
buildings  with  a  copy  of  every  permit  allowing  any  plumbing  work,  whether 
of  new  installation,  alteration,  or  repair.  The  inspector  of  buildings  and  the 
commissioner  of  health  must  formulate  rules  and  regulations  consistent  with 
the  ordinances  for  the  execution  of  plumbing  work.  This  section  of  the  build¬ 
ing  code  includes  substantially  the  points  covered  by  the  regulations  of  the 
commissioner  of  health  of  1898,  but  it  amplifies  them  and  provides  more 
specifically  for  the  details  of  construction. 

In  succeeding  ordinances,  the  powers  granted  to  the  commissioners  of  health 
in  regard  to  nuisances  had  expanded  so  as  to  cover  all  forms  of  nuisances 
arising  from  defective  surface  and  roof  drainage,  the  collection  of  standing 
water  in  utensils  within  and  without  dwellings  and  other  buildings,  and  the 
collection  of  rubbish,  the  presence  of  weeds,  grass,  cans,  bottles,  and  the  like. 
Orders  to  abate  nuisances  have  been  issued  directly  by  commissioners,  inspectors, 
health  wardens,  and  police  officers.  Such  orders  have  gone  primarily  to  oc¬ 
cupiers  of  dwellings  or  buildings,  and  if  not  obeyed,  to  the  owners  or  to  their 
agents. 

FOODS. 

The  ordinances  of  March  30,  1797,  and  July  17,  1797,  provided  that  all 
salt  beef,  pork,  and  fish  brought  into  the  city  be  made  merchantable,  sound, 
and  fit  for  use,  and  authorized  inspection  of  these  articles. 

The  clerks  of  the  markets  were  empowered  by  the  ordinance  of  March  25, 
1805,  to  prevent  the  sale  of  all  blown,  stuffed,  unsound,  or  unwholesome  pro¬ 
visions  and  to  regulate  the  weighing  of  them  by  standard  scales. 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  75 

On  May  30,  1855,  an  ordinance  was  passed,  forbidding,  under  a  penalty  of 
$20  fine,  the  “adulteration  of  milk  offered  for  sale  or  sold  in  Baltimore  by  mixing 
with  it  water,  chaulk,  or  any  drug  or  other  article  whatsoever.” 

In  1879,  another  ordinance  was  passed,  making  it  unlawful  to  mix  water, 
any  drug,  or  other  article  with  milk  offered  for  sale,  but,  as  was  the  case  with 
the  ordinance  of  1855,  no  adequate  provision  was  made  by  the  city  government 
for  its  enforcement. 

Bv  the  ordinance  of  May  16,  1894,  amplified  by  the  ordinance  of  March  19, 
1904,  it  was  made  unlawful  to  sell,  expose  for  sale,  or  to  have  upon  his  or  her 
premises,  store,  stall,  stand,  vehicle,  or  elsewhere,  from  or  in  which  milk  or  any 
other  food  products  are  sold  or  delivered,  any  impure,  adulterated,  sophisticated, 
or  unwholesome  milk  or  other  food  products,  or  any  tainted,  unsound,  rotten,  or 
partly  decomposed  fish,  fruit,  vegetables,  meat,  or  any  food  product  that  is  kept 
fresh  by  salicylic  or  boracic  acid  or  other  preservative.  It  was  the  duty  of  the 
commissioner  of  health  to  have  inspected  milk,  meat,  fish,  and  vegetables 
wherever  such  articles  are  sold,  kept,  or  offered  for  sale  in  the  city  and  to  obtain 
samples  of  milk  and  all  other  food  products  whose  qualities  are  to  be  determined 
by  chemical  and  microscopical  examination  and  to  make  the  necessary  rules 
and  regulations  governing  these  products.  Provision  was  made  in  the  ordinance 
of  1894  for  the  appointment  of  the  chemist  and  three  inspectors.  According 
to  the  milk  standards  set  by  this  ordinance,  there  could  be  sold  in  Baltimore 
only  pure,  unadulterated,  unsophisticated  milk,  the  natural  product  of  healthy 
cows,  not  deprived  of  any  part  of  its  cream,  and  to  which  no  additional  liquid 
or  solid  or  preservative  had  been  added,  and  which  at  60°  F.  would  have  a 
specific  gravity  of  not  less  than  1.029,  not  less  than  12  per  cent  of  total  solids, 
and  not  less  than  3  per  cent  of  butter  fat.  All  milk  sold,  received,  kept,  offered 
for  sale,  or  delivered  in  the  City  of  Baltimore,  could  not  in  any  particular  be 
under  the  standard  described,  without  being  considered  impure,  adulterated, 
sophisticated,  or  unwholesome.  Nothing  in  this  ordinance  was  to  be  construed 
to  prevent  the  sale  of  skim  milk  or  buttermilk,  provided  they  be  sold  as  such 
and  in  every  instance  the  purchasers  be  notified  of  their  true  character. 

The  ordinance  of  April  21,  1896,  regulated  the  ventilation,  flooring,  and 
cleanliness  of  cow  stables.  The  floors  were  to  be  of  cement  or  other  non¬ 
absorbent  materials,  with  grades  and  channels  to  carry  off  drainage  connected 
with  the  public  sewer,  if  one  abutted  the  premises.  The  stables  for  cows  for 
dairy  purposes  were  to  have  sufficient  troughs  and  boxes  for  feeding  and  a 
covered  water-tight  receptacle  outside  of  the  building  for  the  reception  of  dung 
or  other  refuse.  No  privy,  cesspool,  urinal,  inhabited  rooms,  or  workshops  were 
to  be  located  within  any  building  or  shed  used  for  stabling  cows  for  dairy  pur¬ 
poses  or  for  the  storage  of  milk  or  cream ;  nor  was  any  fowl,  hog,  horse,  sheep, 
or  goat  to  be  kept  in  any  rooms  used  for  such  purposes.  The  stalls  for  such 
cows  were  to  be  not  less  than  4  feet  in  width.  The  premises  on  which  cows  were 
to  be  kept  for  dairy  purposes  were  to  be  kept  thoroughly  clean  and  in  good 
repair,  and  well  painted  and  whitewashed  at  all  times.  Every  cow  was  to  be 
cleaned  and  properly  fed  and  watered  each  day.  This  ordinance  made  compul¬ 
sory  the  prompt  reporting  to  the  health  department  not  only  of  the  occurrence 
of  contagious  and  infectious  diseases  among  cows,  but  of  cases  of  Asiatic  cholera, 
croup  and  diphtheria,  measles,  scarlatina,  small-pox,  and  typhus  and  typhoid 

6 


76 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


fevers  upon  the  premises  with  milch  cows,  or  where  milk  is  handled  or  offered 
for  sale.  Milk  from  premises  where  there  were  cases  of  any  of  these  or  other 
infectious  diseases  could  not  be  sold  nor  given  away  until  the  commissioner  of 
health  deemed  it  safe.  Persons  connected  with  dairying  and  milk  handling  were 
forbidden  to  enter  such  premises.  The  tuberculin  test  for  milch  cattle  within 
the  city  was  required. 

The  sanitary  conditions  under  which  milch  cattle  could  be  kept  were  made 
more  stringent  by  the  ordinance  of  May  13,  1902,  which  required  non-absorbent 
floors  in  stables,  with  proper  drainage  and  more  air-space  and  range  for  cows. 

By  the  changes  in  the  code  of  1906,  the  city  government  was  given  extensive 
powers  to  control  food  products. 

In  1908,  a  sweeping  ordinance  was  passed,  giving  the  health  department 
greater  control  over  the  milk-supply,  requiring  permits  for  handling  milk, 
making  provision  for  dairy-farm  inspection,  excluding  for  sale  the  milk  of 
slop-fed  cows,  the  cleansing  of  utensils,  the  regulation  of  conditions  under 
which  milk  could  be  sold,  and  raising  the  standard  for  total  solids  to  12.5  per 
cent  of  butter  fat  to  3.5  per  cent. 

The  ordinance  of  June  1,  1917,  amended  the  former  milk  ordinances  so  as 
to  give  the  commissioner  of  health  complete  control  over  the  milk  and  the 
milk-supply  from  the  farm  to  the  table.  To  this  end  it  reaffirmed  the  provision 
for  dairy  inspection,  permits  for  shipping  milk  to  the  city,  and  permits  for  the 
sale  of  milk  within  the  citv.  It  also  established  bacterial  standards  for  raw  milk 
and  rules  and  regulations  for  the  pasteurization,  cooling,  labeling,  and  bottling 
of  milk  sold  within  the  city  and  for  the  cleansing  and  sterilization  of  milk  cans, 
bottles,  pasteurizing  apparatus,  and  all  other  utensils  connected  with  the  milk 
industry.  All  the  raw  milk  sold  must  come  from  non-tuberculous  cows  and 
must  not  have  a  bacterial  count  of  over  50,000  per  cubic  centimeters.  Selected 
pasteurized  milk  and  selected  pasteurized  cream  must  come  from  tuberculin- 
tested  cows  and  contain  not  over  200,000  bacteria  per  cubic  centimeters  before 
pasteurization  and  not  more  than  30,000  bacteria  per  cubic  centimeters  after 
pasteurization  prior  to  delivery.  Standard  milk  pasteurized  must  contain  not 
more  than  100,000  bacteria  per  cubic  centimeters  after  pasteurization  and  prior 
to  delivery  and  not  more  than  1,500,000  per  cubic  centimeters  before  pasteuriza¬ 
tion.  “  Pasteurized  milk  shall  be  milk  which  has  been  uniformly  heated  to  a 
temperature  between  140°  F.  and  150°  F.  and  maintained  at  that  temperature 
for  not  less  than  30  minutes  and  cooled  immediately  to  a  temperature  of  45° 
or  less.”  Milk  and  cream  falling  below  the  requirements  for  standard  milk  pas¬ 
teurized  or  standard  cream  pasteurized  are  called  “  below-standard  milk  ”  and 
may  be  sold  only  under  the  authority  of  the  commissioner  of  health  and  for  only 
such  purposes  and  in  accordance  with  such  restrictions  and  regulations  as  may 
be  prescribed  by  him. 

III.  STATE  OF  MAKYLAND. 

After  the  passage  of  the  quarantine  laws  previously  alluded  to,  nearly  100 
years  elapsed  before  the  passage  by  the  State  Legislature  of  any  State  laws, 
with  the  exception  of  those  establishing  the  State  vaccine  institute  or  agency  in 
1864,  that  influenced  either  directly  or  indirectly  the  public-health  administra¬ 
tion  of  Baltimore.  The  law  establishing  the  State  Board  of  Health  was  passed 
in  1874. 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  77 

CONTAGIOUS  AND  INFECTIOUS  DISEASES. 

In  1882,  the  same  year  in  which  the  city  ordinance  required  the  reporting 
to  the  commissioner  of  health  by  physicians  and  others  of  cases  of  certain  com¬ 
municable  diseases,  the  State  Legislature  passed  a  law  empowering  the  health 
authorities  of  any  city  or  town  or  the  justice  of  peace  of  any  county  of  Mary¬ 
land,  on  the  certificate  of  a  qualified  medical  practitioner,  to  order  “  the  cleans¬ 
ing  and  disinfecting  of  any  house  or  part  thereof,  and  any  articles  therein 
likely  to  retain  infection,”  when  in  their  opinion  these  acts  would  tend  to  check 
or  prevent  infectious  diseases,  and  where  the  owner  or  occupier  of  such  a  house 
was  unable  to  carry  out  these  requirements,  the  local  authorities  were  empowered 
to  carry  out  such  procedures  at  the  public  expense.  The  law  further  provided 
that: 

“  Any  person  who,  while  suffering  from  any  dangerous  infectious  disorder,  wilfulty  ex¬ 
poses  himself  or  herself,  without  any  proper  precautions  against  spreading  said  dis¬ 
order  in  any  street,  public  place,  shop,  inn,  or  public  conveyance,  without  previously 
notifying  the  owner,  conductor,  or  driver  that  he  is  so  suffering,  or  being  in  charge  of 
any  person  so  suffering,  so  exposes  such  sufferer,  or  gives,  lends,  sells,  transmits,  or 
exposes,  without  previous  disinfection,  any  bedding,  clothing,  rags,  or  other  things  which 
had  been  exposed  to  infection  from  any  such  disorder,  shall  be  liable  to  a  penalty  not 
exceeding  $500,  or  imprisonment  not  exceeding  twelve  months,  or  both,  in  the  discre¬ 
tion  of  the  circuit  court  for  the  county  or  criminal  court  of  Baltimore.  Any  person  who 
carelessly  carries  children  or  others  infected  with  infectious  diseases  or  who  knowingly 
introduces  infected  persons  into  other  person’s  premises,  or  permits  children  under  his 
or  her  care  to  attend  any  school,  theater,  church  or  other  public  place  where  they 
will  be  brought  in  contact  with  others,  shall  be  liable  to  a  penalty  not  exceeding  $100 
for  each  and  every  offence.” 

Owners  or  drivers  of  public  conveyances  were  required-  to  disinfect  sucli  con¬ 
veyances  as  approved  by  the  local  health  authority,  after  conveying  in  them 
anyone  suffering  from  any  dangerous  or  infectious  disorder  or  the  corpse  of 
anyone  who  has  died  from  any  such  disorder.  It  was  forbidden  to  let  for  hire 
any  house,  room,  or  part  of  a  house  in  which  any  person  had  suffered  from  a 
dangerous  or  infectious  disorder  without  having  it  and  all  articles  therein  liable 
to  retain  infection  disinfected  to  the  satisfaction  of  a  qualified  medical  prac¬ 
titioner.  Any  health  officer  or  justice  of  the  peace  was  given  the  power  to  cause 
to  be  removed  or  buried  at  public  cost  the  body  of  anyone  who  had  died  of 
infectious  diseases  which  was  retained  in  a  room  in  which  persons  were  living 
or  sleeping,  or  any  dead  body  which  was  in  such  a  state  as  to  endanger  the  health 
of  the  inmates  of  a  house  or  room.  Notification  of  cases  of  infectious  diseases 
was  not  required  by  State  law  until  1898. 

By  act  in  1904,  the  State  Board  of  Health  was  required  to  keep  a  register  of 
all  persons  in  the  State  known  to  be  affected  with  tuberculosis.  The  superinten¬ 
dent  or  other  person  in  charge  of  any  hospital,  dispensary,  school,  reformatory, 
or  other  institution  which  derived  the  whole  or  any  part  of  its  support  from  the 
public  funds  of  the  State  of  Maryland,  or  of  any  city,  town,  or  county  of  the 
State,  having  in  charge  or  under  care  or  custody  any  person  or  persons  suffering 
with  pulmonary  or  laryngeal  tuberculosis,  wras  to  report  that  fact  to  the  State 
Board  of  Health  within  48  hours  after  the  recognition  of  such  disease.  Any 
physician  who  knew  that  any  person  under  his  professional  care  was  afflicted 
with  pulmonary  or  laryngeal  tuberculosis  was  required  to  transmit  to  the  State 


78  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

Board  of  Health  within  7  days  a  report  of  the  case  on  blanks  provided  by  the 
State  Board  of  Health.  The  same  law  provided  that  apartments  occupied  by  any 
consumptive  were  to  be  disinfected  by  the  board  of  health  of  the  city,  town,  or 
county  when  they  had  been  vacated  by  the  death  or  removal  of  the  consumptive 
occupant.  Persons  were  forbidden  to  permit  anyone,  for  hire  or  otherwise,  to 
occupy  such  apartments  before  such  disinfection.  By  the  same  act,  persons  af¬ 
fected  by  any  disease,  the  infective  agent  of  which  is  contained  in  the  sputum, 
saliva,  or  other  bodily  secretion  or  excretion,  who  might  dispose  of  the  sputum, 
saliva,  or  other  bodily  secretion  or  excretion  in  a  manner  that  might  cause 
offence  or  danger  to  any  person  or  persons  occupying  the  same  room  or  apart¬ 
ment,  house,  or  part  of  a  house,  were  to  be  deemed  guilty  of  a  nuisance  upon 
complaint.  It  was  to  he  the  duty  of  the  commissioner  of  health  or  of  any  local 
health  officer  receiving  such  complaint,  if  the  complaint  be  substantiated,  to 
serve  notice  upon  the  person  so  complained  of  and  to  require  him  to  dispose 
of  his  sputum,  saliva,  and  other  bodily  secretion  or  excretion  in  such  manner  as 
to  remove  all  reasonable  cause  of  offence  or  danger.  It  was  made  the  duty  of 
the  physician  attending  any  case  of  pulmonary  or  laryngeal  tuberculosis  to 
provide  for  the  safety  of  all  individuals  occupying  the  same  house  or  apart¬ 
ment,  and  if  no  physician  he  in  attendance  upon  such  a  patient,  this  duty 
should  devolve  upon  the  local  health  authority.  The  local  health  authority  was 
required  to  furnish  to  physicians  reporting  any  case  of  pulmonary  or  laryngeal 
tuberculosis  a  printed  report,  prepared  and  authorized  by  the  State  Board  of 
Health,  setting  forth  the  precautions  necessary  or  desirable  to  be  taken  on  the 
premises  of  the  said  tuberculosis  case.  If  the  attending  physician  were  unable  or 
unwilling  to  take  the  procedures  and  precautions  specified,  these  duties  then 
were  to  devolve  upon  the  local  health  authority.  Physicians  who  carried  out 
the  procedures  recommended  were  to  receive  on  the  order  of  the  local  board  of 
health  a  fee  of  $1.50,  to  be  paid  by  the  State  Board  of  Health.  To  such  physi¬ 
cians  an  order  on  the  State  Board  of  Health  for  materials  (disinfectants,  spu¬ 
tum-cups,  etc.)  were  to  be  issued  for  the  prevention  of  the  spread  of  the  disease. 

By  an  act  of  1894,  it  was  provided  that  “  if  at  any  time  within  two  weeks 
after  the  birth  of  any  infant,  one  or  both  of  its  eyes,  or  the  eyelids,  be  reddened, 
inflamed,  swollen,  or  discharging  pus,  the  midwife,  nurse,  or  person  other  than 
a  legally  qualified  physician,  in  charge  of  such  infant,  shall  refrain  from  the 
application  of  any  remedy  for  the  same,  and  shall  immediately  report  such  con¬ 
dition  to  the  health  commissioner  or  to  some  legally  qualified  physician  in  the 
city,  county,  or  town  wherein  the  infant  is  cared  for.” 

In  1911,  the  legislature  authorized  the  State  Board  of  Health  to  provide 
the  “  Pasteur  antirabic  treatment 99  for  the  prevention  of  hydrophobia,  free  of 
charge  to  those  unable  to  pay  for  it. 

VACCINATION. 

In  1864,  it  was  required  of  every  practicing  physician  in  the  State  that  he 
vaccinate  all  children  in  the  circuit  of  his  practice  who  might  be  presented  to 
him  for  vaccination  within  one  year  after  birth,  if  such  children  be  in  proper 
condition  for  such  service,  and  all  other  persons,  not  previously  effectually 
vaccinated,  who  might  request  such  service  from  him.  There  was  a  penalty  of 
$5  for  non-observance  of  this  duty.  Physicians  were  also  forbidden  under 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  79 

penalty  of  not  less  than  $100  nor  more  than  $500  to  use  any  virus  defective  in 
its  nature  by  having  passed  through  a  scrofulous  system,  or  by  having  been 
taken  from  one  laboring  under  any  disease  of  the  skin,  chronic  sore,  or  other 
febrile  or  other  disease,  or  any  crust  which,  during  the  progress  of  the  vaccine 
disease,  was  punctured  or  had  sustained  other  injury.  Every  patient  or  guardian 
was  required  to  have  his  or  her  child  vaccinated  within  12  months  after  its  birth, 
if  it  was  in  proper  condition,  or  as  soon  thereafter  as  practicable,  and  any  other 
person  under  his  or  her  control  or  care  was  to  be  vaccinated  prior  to  November  1 
of  each  year.  School-teachers  were  forbidden  to  receive  into  schools,  as  scholars, 
persons  without  the  certificate  of  some  regular  practising  physician  that  such 
applicants  for  admission  into  the  schools  have  been  duly  vaccinated.  By  the 
legislative  act  of  1867,  the  State  vaccine  agent  was  required  to  take  all  steps 
necessary  to  reproduce  from  the  cow  true  vaccine  virus  for  the  use  of  physicians 
residing  and  practising  medicine  and  surgery  in  the  State.  He  vras  forbidden 
to  furnish  such  virus  more  than  four  removes  from  the  cow  if  practicable  and 
none  that  had  not  been  produced  under  his  own  supervision  and  direction,  pro¬ 
vided  that  he  might  use  and  furnish  virus  furnished  him  by  any  physician 
intrusted  by  him  to  procure  it,  such  virus  not  to  be  taken  from  the  arm  of  a 
child  less  than  three  months  old. 

MEDICAL  PRACTICE. 

The  first  State  act  concerning  medical  practice,  which  was  passed  in  1888 
and  amended  in  1892,  placed  the  examinations  and  medical  qualifications  in 
the  hands  of  two  separate  examining  boards ;  one  represented  the  Medical  and 
Chirurgical  Faculty  and  the  other  the  Maryland  State  Homeopathic  Society. 

REGISTRATION  AND  LICENSES. 

By  act  of  the  legislature  of  1910,  all  midwives  in  practice  previous  to  July 
1,  1910,  were  required  to  register  with  the  local  register  of  vital  statistics,  and 
no  one  was  allowed  to  practice  as  midwife  after  this  date  without  license  granted 
after  examination  by  the  State  Board  of  Health. 

By  1910,  the  legislature  had  passed  laws  regulating  the  admission  into  the 
occupations  of  pharmacy,  nursing,  undertaking,  plumbing,  and  barbering. 

REGISTRATION  OF  BIRTHS  AND  DEATHS. 

The  first  State  law  requiring  the  registration  of  births  and  deaths  was  passed 
in  1898.  By  this  law  the  Secretary  of  the  State  Board  of  Health  was  made  the 
registrar  of  vital  statistics  and  became  responsible  for  the  methods  and  forms 
of  registration  and  for  the  tabulation  and  preservation  of  the  facts.  Local 
health  officers  of  counties,  towns,  and  cities  were  made  local  registrars,  and 
physicians  became  subregistrars  and  were  directed  to  make  returns  to  the  local 
resristrars  of  births  and  deaths  on  suitable  forms  furnished  by  the  secretary  of 
the  State  Board  of  Health.  Death  certificates  of  individuals  dying  without 
the  attendance  of  physicians  were  required  to  be  made  out  by  undertakers, 
coroners,  or  others  having  knowledge  of  them.  Midwives  were  allowed  to  make 
returns  of  births  if  no  physicians  were  in  attendance.  Notifications  to  the  local 
registrar  of  births  and  deaths  were  required  of  parents,  of  householders,  and  of 


80  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

the  superintendents  of  workhouses,  houses  of  correction,  prisons,  hospitals, 
reformatories,  almshouses,  and  other  institutions,  and  by  masters  or  other 
commanding  officers  of  ships  or  other  vessels.  Whereas,  under  this  system,  the 
originals  of  birth  and  death  certificates  were  required  to  be  sent  to  the  secretary 
of  the  State  Board  of  Health  as  registrar  of  the  State,  this  had  never  been  made 
to  apply  to  the  City  of  Baltimore.  With  the  revision  of  the  registration  laws  of 
1900,  it  was  provided  that  in  the  case  of  births  and  deaths  occurring  within  the 
City  of  Baltimore,  the  State  registrar  would  not  require  the  return  to  him  of 
the  original  certificates  of  births  and  deaths,  but  only  such  transcripts,  tables, 
figures,  and  compilations  as  might  seem  to  him  advisable  or  necessary.  Under 
this  provision,  the  State  registrar  was  to  be  furnished  by  the  commissioner  of 
health  either  with  duplicates  or  with  punched  cards.  The  enactment  of  1904 
required  that  still-born  children  be  registered  under  both  births  and  deaths,  and 
a  certificate  of  both  birth  and  death  was  to  be  filed  with  the  local  registrar  in 
the  usual  form  and  manner ;  the  certificate  of  birth  to  contain  in  the  place  for 
the  name  of  the  child  the  word  “  still-birth ”  and  the  death  certificate  to 
enter  the  cause  of  death  as  “  still-born.”  A  burial  or  removal  permit  of  the 
usual  form  was  required.  Under  this  law,  midwives  were  not  to  be  allowed  to 
sign  certificates  of  death  for  still-born  children.  . 

The  State  Lunacy  Commission,  with  broad  powers,  was  established  by  an 
act  of  1886. 

CHILD  LABOR  LAWS. 

By  an  act  of  legislature  of  1888,  amended  in  1892,  the  employment  of 
children  under  16  years -of  age  in  any  manufacturing  or  mercantile  business  for 
more  than  10  hours  a  day  was  forbidden.  The  law  of  1896  forbade  the  employ¬ 
ment  of  children  under  12  years  of  age  in  any  mill  or  factory  within  the  State, 
but  this  act  did  not  apply  to  16  counties  of  the  State,  including  Baltimore 
County.  According  to  the  act  of  1912,  as  amended  in  1914,  1916,  1918,  and 
1920,  children  under  14  years  of  age  were  not  permitted  to  work  in  any  industry 
and  could  not  work  for  hire  in  any  business  or  service  whatsoever  during  school 
hours.  Boys  under  12  and  girls  under  16  were  not  allowed  to  sell  newspapers. 
Children  under  16  years  of  age  were  entirely  excluded  from  factories  in  which 
machines  were  operated;  chemical,  paint,  and  dye  works;  heavy  work  in  the 
building  trades ;  manufactories  involving  the  escape  of  poisonous  gases ;  tobacco 
factories ;  work  in  tunnels  and  mines ;  and  theatrical  and  concert-hall  appear¬ 
ances.  No  child  under  18  years  of  age  was  permitted  to  work  in  or  about  blast 
furnaces,  docks,  and  wharves,  or  with  electric  wiring.  They  were  forbidden  to 
run  elevators,  to  work  with  dynamos,  to  oil  machinery  in  motion,  or  to  take  part 
in  the  operation  of  polishing  or  buffing  wheels.  They  could  not  be  employed  as 
railroad  hands,  trainmen,  telegraphers,  pilots,  firemen,  or  engineers,  or  in 
connection  with  explosives,  in  the  manufacture  of  phosphorus  matches,  or  in 
the  manufacture  or  distribution  of  alcoholic  liquors.  No  minor  could  be 
employed  in  connection  with  a  barroom. 

GENERAL  LABOR  LAWS. 

Between  1904  and  1914,  the  legislature  enacted  health  laws,  governing  labor 
in  factories,  workshops,  and  dwellings,  and  designed  to  insure  adequate  sani- 


DEVELOPMENT  OF  HEALTH  DEPARTMENT  AND  HEALTH  LAWS,  ETC.  81 

tary  surroundings,  to  guarding  against  individuals  with  communicable  diseases, 
and  to  protect  child  labor. 

By  an  act  in  1896,  the  proprietors  or  owners  of  retail,  jobbing,  or  wholesale 
stores,  or  any  other  place  where  female  help  was  engaged  for  the  purpose  of 
serving  the  public  in  the  capacity  of  clerks  or  sales  ladies  were  to  provide  a 
chair  or  stool  for  each  one  of  such  female  help  or  clerk. 

The  legislative  enactment  of  1884  provided  that  all  factories,  manufacturing 
establishments,  or  workshops  within  the  State  were  to  be  kept  in  a  cleanly  con¬ 
dition  and  free  from  effluvia  arising  from  any  drain,  privy,  or  other  nuisance, 
forbade  overcrowding  injurious  to  health  of  persons  employed  therein,  and 
required  sufficient  light  and  ventilation  to  render  harmless,  so  far  as  prac¬ 
ticable,  all  the  gases,  vapors,  dust,  or  other  impurities  generated  in  the  course 
of  the  manufacturing  processes  or  handicraft  carried  on  therein  which  might 
be  injurious  to  health. 

By  an  act  of  1894,  the  manufacture  or  sale  of  clothing  and  other  articles  in 
places  or  under  circumstances  endangering  the  public  health  was  forbidden : 

“  Any  room  or  apartment  which  shall  not  contain  at  least  400  cubic  feet  of  clear  floor 
space  for  each  person  habitually  laboring  in  or  occupying  the  same,  or  wherein  the 
thermometer  shall  habitually  stand,  during  the  hours  of  labor,  at  or  above  80°  F.,  be¬ 
fore  the  first  day  of  May  or  after  the  first  day  of  October  of  any  year,  or  wherein  any 
person  suffering  from  a  contagious,  infectious,  or  otherwise  dangerous  disease  or  malady 
shall  sleep,  labor,  remain,  or  wherein,  if  of  less  superficial  area  than  500  square  feet, 
any  artificial  light  shall  be  habitually  used  between  the  hours  of  8  a.  m.  and  4  p.  m.,  or 
from  which  the  debris  of  manufacture  and  all  other  dirt  or  rubbish  shall  not  be  re¬ 
moved  at  least  once  in  every  twenty-four  hours,  or  which  shall  be  pronounced  ill- 
ventilated  or  otherwise  unhealthy  by  any  officer  or  board  having  legal  authority  so  to 
do,  shall  be  deemed  a  place  involving  danger  to  the  public  health.” 

By  an  act  of  1896,  it  was  unlawful — 

“  for  any  person,  agent,  owner,  or  proprietor  of  a  sweatshop  or  factory  where  four 
or  more  persons  are  employed,  to  use  coal  oil,  gasoline  or  other  explosive  or  in¬ 
flammable  compound  for  the  purpose  of  lighting  or* heating  in  any  form;  any  person, 
agent,  owner  or  proprietor  violating  the  provisions  of  this  section  shall  be  guilty  of  a 
misdemeanor,  and  on  conviction  thereof,  to  be  fined  by  the  court  before  whom  such 
conviction  is  had,  for  every  violation,  the  sum  of  one  hundred  dollars  and  costs,  and 
stand  committed  until  such  fine  and  costs  be  paid. 

“  The  owner  or  owners  of  any  such  house  or  building  used  as  a  sweatshop  or  factory 
where  four  or  more  persons  are  employed  as  garment  workers,  on  other  than  the 
first  floor  of  such  house  or  building,  shall  provide  fire  escapes  for  the  same;  and  if 
any  owner  or  owners  of  any  house  or  building  so  used  fail  to  make  or  provide  a  fire 
escape  within  six  months  after  the  passage  of  this  act,  upon  conviction  thereof  shall 
pay  a  fine  of  two  hundred  dollars,  to  be  recovered  as  other  fines  in  this  State,  or  im¬ 
prisonment  in  the  city  jail  for  sixty  days,  or  both  fine  and  imprisonment,  in  the  discre¬ 
tion  of  the  court” 

An  act  of  legislature  in  1910  required  the  proprietors  and  managers  of  shirt 
factories  in  the  State  of  Maryland  to  sprinkle  the  floors  every  morning  with 
water. 

NUISANCES. 

An  act  of  1886  gave  the  State  Board  of  Health  control  over  nuisances  affect¬ 
ing  the  water-supply  of  any  city,  town,  or  village.  A  similar  act  in  1888  made 
it  unlawful  to  pollute  the  ponds  or  streams  used  for  obtaining  ice,  and  forbade 
the  dumping  from  ships,  scows,  steamboats,  and  other  vessels  of  any  ballast, 


82 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


ashes,  filth,  earth,  soil,  oysters,  or  oyster  shells  in  the  Chesapeake  Bay  above 
Sandy  Point  or  in  the  waters  of  Herring  Bay  or  in  any  river,  creek,  or  harbor 
Vithin  the  State  below  high-water  mark. 

FOOD. 

The  legislature  in  1890  passed  a  broad  act  directed  against  the  coloring, 
staining,  adulteration,  or  other  sophistication  of  any  article  of  food  or  drink, 
mislabeling,  and  misbranding,  and  charged  the  State  Board  of  Health  with 
enforcing  the  same,  and  at  the  same  time  gave  it  power  over  the  inspection  and 
examination  of  all  animal  and  vegetable  food-stuffs,  including  milk. 

INSPECTION. 

The  Live  Stock  Sanitary  Board,  established  by  an  act  of  the  legislature  in 
1888,  was  given  oversight  of  contagious  and  infectious  diseases  in  animals 
and  control  over  dairymen  and  others  supplying  milk  to  cities,  and  established 
sanitary  rules  in  regard  to  stables  for  cattle  and  buildings  in  which  milk  is 
kept  or  sold. 

These  powers  and  duties  were  extended  by  the  act  of  1916,  by  which  the  whole 
matter  was  placed  under  the  State  Board  of  Agriculture,  with  greatly  increased 
powers  and  duties  in  regard  to  the  inspection  of  dairies  and  dairy  cattle,  milk, 
creameries,  cattle,  and  meat. 

By  an  act  of  the  legislature  in  1880,  amended  in  1888,  inspection  was  pro¬ 
vided  for  the  safety  of  buildings  used  for  amusement,  worship,  and  lodging  in 
the  cities  of  the  State. 


PART  III.— PUBLIC  HEALTH  ADMINISTRATION  OF 

BALTIMORE. 


Chapter  V. — Public  Health  Measures 

WITHOUT  THE  ClTY. 

Development  of  quarantine  laws  and  practices;  The  lazaretto  and  quar¬ 
antine  hospitals  of  the  Port  of  Baltimore:  Effectiveness  of  maritime 
quarantine. 

THE  DEVELOPMENT  OF  QUARANTINE  LAWS 

AND  PRACTICES. 

In  Baltimore  the  fight  concerning  the  quarantine  restrictions  to  be  imposed 
on  the  port  centered  about  the  question  of  yellow  fever.  Concerning  small-pox 
and  probably  typhus  fever  there  was  no  controversy.  Was  yellow  fever  con¬ 
tagious  or  non-contagious;  was  it  imported  or  of  local  origin?  Upon  the 
decision  of  these  questions  depended  the  quarantine  policies  and  the  mercan¬ 
tile  interests  of  the  young  city.  The  fight  over  these  questions  lasted  until  1825. 
The  Philadelphia,  New  York,  and  Boston  ports  held  to  the  official  British 
doctrine  that  the  disease  was  contagious  and  was  imported.  These  cities, 
Philadelphia  in  particular,  developed  stringent  quarantine  laws  against  this 
disease.  In  Charleston,  the  southern  port  of  greatest  importance,  it  would 
seem  that  the  contrary  view  was  held,  for  the  celebrated  Dr.  Ramsey  (31),  of 
Charleston,  in  a  letter  to  Dr.  Miller,  of  New  York,  under  date  of  November  18, 
1800,  stated  that — 

“  Disputes  about  the  origin  of  yellow  fever,  which  have  agitated  the  Northern  States, 
have  never  existed  in  Charleston;  there  is  but  one  opinion  among  the  physicians  and 
inhabitants,  and  that  is  that  the  disease  was  neither  imported  nor  contagious.  It  was 
the  unanimous  sentiment  of  the  medical  society,  who,  in  pursuance  of  it,  gave  their 
opinion  to  the  Government  last  summer,  that  the  rigid  enforcement  of  the  quarantine 

laws  was  by  no  means  necessary  on  account  of  the  yellow  fever . My  private 

opinion  is  that  the  yellow  fever  is  a  local  disease,  originating  in  the  air  of  Charleston.” 

At  the  time  of  the  outbreak  of  the  great  yellow-fever  epidemic  in  Philadelphia 
in  1793,  it  was  not  questioned  by  any  authority,  north  of  Charleston,  South 
Carolina,  at  least,  that  the  disease  was  imported  and  not  of  local  origin. 
Deveze  (32),  the  resident  physician  of  the  yellow  fever  hospital  of  Philadelphia, 
published  a  paper  in  December  of  that  year  in  which  he  laid  down  the  doctrine 
that  yellow  fever  is  not  contagious,  but  this  apparently  attracted  no  attention. 
Deveze  came  to  Philadelphia  from  the  West  Indies,  shortly  before  or  during 
the  time  of  the  yellow-fever  epidemic,  and  as  we  have  already  learned  through 
Lind,  some  physicians  at  least  in  the  West  Indies  denied  that  this  disease  is 
carried  by  contact.  Dr.  Benjamin  Rush,  with  the  rest  of  the  leading  physicians 
of  Philadelphia,  then  believed  the  disease  to  be  imported  and  spread  by  personal 
contact.  As  we  have  already  seen,  the  governor  of  Maryland  instituted  as  vigor¬ 
ous  a  quarantine  as  he  could  against  Philadelphia  at  that  time,  and  this  quaran- 

83 


84  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

tine  was  maintained  not  only  by  the  governor  but  by  the  local  authorities  of 
Baltimore  each  succeeding  year  until  1797.  Dr.  John  B.  Davidge,  of  Baltimore, 
is  commonly  given  the  credit  for  the  first  printed  enunciation  in  the  United 
States  that  yellow  fever  is  not  contagious.  This  statement  was  first  printed  in 
the  Federal  Gazette  of  Baltimore  on  November  30,  1797,  nearly  eight  months 
after  the  passage  of  the  first  health  ordinance  of  the  City  of  Baltimore.  In  1798, 
Dr.  Davidge  (33),  published  A  Treatise  on  the  Autumnal  Endemical  Epi- 
demick  of  Tropical  Climates ,  Vulgarly  Called  the  Yellow  Fever ,  in  which  he 
defined  the  disease  as  follows : 

“  The  yellow  fever,  synonymous  with  la  maladie  de  Siam,  or  la  fevre  matelotte  of  the 
French  and  vomito  prieto  of  the  Spaniards,  is  the  majority  or  acme,  as  the  intermit¬ 
tent  is  the  embryo,  of  the  remittent  bilious  fever;  it  is  to  the  common  bilious  what  the 
confluent  is  to  the  common  mild  smallpox ;  they  are  in  kind  the  same;  a  specific  difference 
only  exists  between  them.  It  is  conceived  in  the  same  matrix  and  quickened  by  the 
same  sun,  it  is  indigenous  to  America  and  to  all  other  warm  climates,  it  is  the  very  out¬ 
let  to  Americans  and  Britons,  from  life  to  the  grave.” 

Davidge  suggested  that  as  the  malarial  fevers,  including  yellow  fever,  are 
admittedly  caused  by  marsh  effluvia,  and  as  the  latter  appear  to  be  decompo¬ 
sition  products  of  both  vegetables  or  of  water,  and,  in  the  decomposition  of 
either,  hydrogen  is  produced  in  considerable  quantities,  and  as  this  is  what 
occurs  in  the  conditions  under  which  marsh  effluvia  are  generated,  the  hydro¬ 
gen  set  free  in  this  decomposition  is  the  “  peccant  agent.”  At  that  time  and  for 
years  previous,  intermittent,  remittent,  and  bilious  fevers  and  dysentery  com¬ 
monly  prevailed  in  the  summer  and  autumn  at  Fell’s  Point  and  to  a  certain 
extent  along  the  low  grounds  contiguous  to  J ones  Falls  and  the  basin.  Fell’s 
Point,  however,  was  always  the  place  of  the  greatest  intensity  of  these  fevers,  and 
it  was  at  Fell’s  Point  that  yellow  fever  always  started.  Alluding  to  the  yellow- 
fever  epidemic  in  Baltimore  in  1797,  Dr.  Davidge,  who  was  a  member  of  the 
committee  on  health  sent  to  Fell’s  Point  to  investigate  the  disease,  stated  that 
the  common  bilious  fever  prevailed  there  as  usual  from  June  and  that  a  little 
later  “  the  disease  raised  from  the  grade  of  bilious  to  yellow  fever  and  mounted 
its  chariot  of  death  and  drove  furiously  through  the  streets.”  He  held,  therefore, 
that  the  malarial  fevers,  particularly  bilious  remittent  fever,  and  yellow-fever 
were  one  and  the  same  disease,  due  to  the  same  cause,  the  effluvia  of  the  decayed 
vegetable  material,  and  of  local  origin.  He  did  not  deny  that  either  of  these 
diseases  could  be  imported,  but  he  did  assert  that  yellow  fever,  when  it  occurred 
in  Baltimore,  was  not  imported.  He  held  that  just  as  the  bilious  fevers  were 
caused  by  decayed  vegetable  material  and  were  not  contagious,  and  as  contagious 
diseases  were  due  solely  to  human  effluvia,  so  diseases  caused  by  effluvia  of 
decayed  vegetable  material  are  endemic  and  are  the  antitheses  of  the  contagious 
diseases. 

During  the  yellow-fever  epidemic  in  Bhode  Island  in  1797,  Dr.  William 
Senter  (34),  the  leading  physician  of  Newport,  and  a  member  of  a  committee 
of  physicians  appointed  to  advise  the  authorities  concerning  the  nature  and 
prevention  of  this  disease,  contended  that  yellow  fever  was  not  contagious  and 
was  of  local  origin  and  not  imported.  His  views  were,  however,  strenuously 
opposed  by  his  colleagues. 

Nathaniel  Potter,  in  the  preface  of  his  Memoir  on  Contagion  (23),  published 
in  1817,  while  giving  full  credit  to  Davidge  for  being  first  to  announce  in  print 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


85 


that  yellow  fever  was  indigenous  and  was  not  contagious,  stated  that  he,  himself, 
reached  these  conclusions  in  the  summer  of  1793,  while  practicing  in  Caroline 
County,  Maryland,  and  quoted  from  a  letter  which  he  wrote  to  Dr.  Benjamin 
Rush,  of  Philadelphia,  his  preceptor,  saying — 

“  that  those  various  forms  of  bilious  fever  unquestionably  owe  their  existence  to  the 
putrefaction  of  matters  on  the  surface  of  the  earth  after  an  uncommonly  wet  spring 
followed  by  the  driest  and  hottest  summer  that  can  be  remembered  by  the  oldest 
inhabitants.  With  all  possible  deference  to  your  superior  judgment,  I  can  not  prevail 
upon  myself  to  believe  that  any  fever  arising  from  vegetable  decomposition  is  conta¬ 
gious.  The  origin  I  have  assigned  to  the  epidemic  of  your  city  is  the  only  one  that  is 
physically  possible,  and,  therefore,  you  place  your  adversaries  on  equal  ground  with 
you  by  acknowledging  the  fever  contagious.  Deny  the  existence  of  contagion  as  un- 
philosophical,  and  you  cut  them  off  from  every  source.  If  we  admit  one  of  the  fevers 
from  marsh  effluvia  to  be  contagious  we  are  bound  (a  priori)  to  admit  them  all  to  be 
so,  intermittent  and  dysenteric.” 

Potter  further  stated  that  when  Dr.  Rush  was  writing  in  April  1794,  on  the 
epidemic  of  the  preceding  year,  he  proposed  to  Potter  to  introduce  into  his 
work  that  part  of  the  above  letter  which  described  the  symptoms  and  treatment 
of  the  epidemic  in  Caroline  County.  To  this  Potter  consented,  provided  Rush 
would  also  print  the  sentiments  expressed,  so  far  as  they  regarded  contagion. 
Rush  declined  to  do  this,  says  Potter,  on  account  of  his  former  belief  “  that  all 
diseases  arising  from  marsh  miasmata  were  contagious  in  a  degree  proportionate 
to  their  malignity  and  that  the  opposite  doctrine  was  untenable.”  Believing 
that  he  was  the  only  person  in  America  who  denied  the  contagion  of  yellow 
fever  and  deeply  impressed  that  this  opinion  could  be  sustained  by  the  facts,  in 
the  summer  of  1795  Potter  selected  this  topic  for  his  inaugural  thesis  at  the 
next  commencement.  He  was  dissuaded  from  this,  however,  by  Dr.  Wistar,  who 
entreated  him  on  the  score  of  policy  and  expediency  to  select  some  other  subject. 

In  regard  to  the  history  of  yellow  fever  in  this  country  and  the  question  as 
to  its  contagious  character,  one  of  the  most  important  contributions  was  that 
of  Stubbins  Ffirth  (35).  He  held  that  the  experiences  of  Hew  York,  Baltimore, 
and  Philadelphia  in  the  recent  yellow-fever  epidemics  had  shown  that  yellow  or 
malignant  fever  is  not  taken  from  the  sick  by  physicians,  nurses,  and  other 
attendants.  He  mentioned  instances  in  which  persons,  including  himself,  had 
slept  in  the  beds  of  yellow-fever  patients  without  contracting  the  disease.  In 
his  experiments  on  cats  and  dogs  he  was  unable  to  reproduce  the  disease  by 
feeding  black  vomit  to  them.  Black  vomit  introduced  into  the  wounds  on  the 
backs  of  dogs  produced  no  ill  effects,  and  in  experiments  on  himself,  including 
the  inoculation  of  black  vomit  into  his  eye,  into  wounds  on  his  arm,  drinking 
it  repeatedly  in  two  successive  epidemics,  inoculation  of  himself  on  or  under 
the  skin  with  the  blood  serum,  the  saliva,  the  perspiration,  and  the  urine  of 
yellow-fever  patients  in  the  height  of  the  disease,  and  finally  drinking  con¬ 
siderable  quantities  of  the  blood  serum  of  yellow-fever  patients,  the  disease  was 
not  produced.  As  all  of  these  experiments,  both  on  animals  and  on  himself,  were 
negative,  he  concluded  that  yellow  fever  is  not  a  contagious  disease. 

Davidge’s  publication  of  1798  had  no  immediate  effect  on  modifying  the 
quarantine  regulations  of  the  first  health  ordinance.  Indeed,  in  1801  and  in 

1807,  they  were  made  more  specific  and  comprehensive  by  amendments.  In 

1808,  however,  the  quarantine  laws  were  entirely  repealed. 


86 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


Meanwhile,  Potter’s  notable  address  on  contagion  had  been  published  in  1817, 
and  the  severe  yellow-fever  epidemic  of  1819  had  been  experienced  and  fully 
written  up  by  Dr.  David  M.  Reese  (25),  and  others  (36).  In  his  address  of  1817, 
from  which  quotations  have  already  been  made,  Potter  reviewed  in  elaborate 
manner  the  history  of  the  ideas  concerning  contagion  and  infection,  the  develop¬ 
ment  of  quarantine  systems  in  general,  the  quarantine  regulations  of  New  York 
and  Philadelphia  in  particular,  and  the  British  quarantine  system.  He  con¬ 
cluded  not  only  that  yellow  fever  was  not  contagious  and  was  of  local  origin,  but 
he  held  up  the  whole  quarantine  system  as  practiced  in  his  day  to  the  severest 
ridicule. 

In  regard  to  plague,  Potter  held  that  the  idea  that  this  disease  is  carried  by 
simple  contact  is  refuted  by  experience  and  by  the  natural  history  of  the  disease. 
He  held  that  at  any  rate,  so  far  as  quarantine  is  concerned,  it  was  of  little  or  no 
importance  in  America,,  for  in  the  form  described  by  foreign  writers  it  had 
never  been  seen  on  our  continent,  although  our  commercial  intercourse  had 
extended  to  all  the  countries  which  had  generated  it.  He  affirmed  that  the 
quarantine  laws  of  no  nation  had  ever  arrested  the  progress  of  any  disease 
except  small-pox,  and  even  despotic  military  discipline  had  failed  to  check  the 
progress  of  the  plague. 

On  the  question  of  quarantine  against  yellow  fever,  Potter  found  himself 
in  agreement  with  President  J efferson,  concerning  whose  position  he  said : 

“  From  the  commencement  of  the  late  pestilential  plague  in  the  United  States,  Mr. 
Jefferson  manifested  a  lively  interest  and  instituted  analytical  investigation  of  the 
origin  of  yellow  fever.  After  an  elaborate  research,  he  declared  the  disease  not  conta¬ 
gious  and  therefore  not  imported.  In  his  communication  to  Congress  in  1804,  on  the 
state  of  the  Union,  he  marks  an  era  in  the  history  of  our  country  as  the  first  public 
functionary  in  the  world,  who  dared  to  think  for  himself  on  this  momentous  subject.” 

Potter  deeply  resented  the  inclusion  by  the  British  government  of  yellow 
fever  among  the  contagious  diseases  to  be  quarantined  on  the  advice  of  medical 
men  unacquainted  with  the  disease.  His  position  in  regard  to  yellow  fever  was 
further  supported  not  only  by  his  own  observations  and  the  experiments  of 
Ffirth,  but  by  his  confirming  in  experiments  on  himself  the  negative  results 
obtained  by  Ffirth.  The  extensive  investigations  in  regard  to  the  etiology  of 
yellow  fever  carried  out  in  Baltimore  during  the  epidemic  of  1819,  as  reported 
by  Reese  and  as  recorded  in  the  collection  of  Extracts  from  a  Series  of  Letters 
and  other  Documents ,  Relating  to  the  Late  Epidemic  or  Yellow  Fever  (36), 
confirmed  the  opinion  so  forcibly  expressed  by  Davidge  and  by  Potter  that 
yellow  fever  in  Baltimore  was  of  local  origin  and  not  a  contagious  disease. 

It  is  to  be  emphasized  that  the  views  in  regard  to  the  nature  of  the  cause 
of  yellow  fever  were  based  not  upon  the  opinions  of  any  one  man,  but  upon 
the  observations  of  a  number  of  keen  observers  and  close  reasoners  among  the 
medical  profession  of  Baltimore.  There  had  been  ample  opportunities  for  these 
observations,  for  yell®w  fever  was  present  in  the  city  in  distinctly  recognized 
epidemics  in  1794,  1797,  1798,  1799,  1800,  1802,  1819,  and  1821.  It  was  also 
probably  present  in  some  at  least  of  the  intervening  years  and  almost  certainly 
in  1807.  During  this  time  there  is  but  one  recorded  observation  of  the  intro¬ 
duction  of  a  case  of  yellow  fever  from  the  outside.  This  case  was  recorded  by 
Davidge  (33),  as  occurring  in  August  1797,  in  a  lady  who  had  recently  come 
from  Philadelphia,  “  who  brought  with  her  the  seeds  of  the  disease,”  and  who 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


87 


was  severely  attacked  with  the  disease  while  walking  on  Charles  Street.  She 
had  the  genuine  black  vomit  for  two  nights  and  a  day.  No  person  in  her 
family  or  in  her  neighborhood  developed  the  disease.  It  was  acknowledged  by 
Reese  that  in  1819  a  few  cases  occurred  on  ships  anchored  off  Fell’s  Point,  but 
it  was  claimed  that  those  people  had  been  ashore,  and  it  was  denied  that  they  had 
the  disease  when  the  ships  arrived. 

Yellow  fever  almost  invariably  began  at  Fell’s  Point,  usually  at  or  near  the 
particular  locality  of  Smith’s  Dock.  The  docks  or  slips  between  the  wharves 
at  Fell’s  Point  were  described  as  being  filthy,  containing  a  large  amount  of 
decaying  vegetable  material  which  only  moved  out  under  the  influence  of  strong 
northwest  winds.  Just  east  of  Fell’s  Point  there  were  large  ponds  filled  with 
stagnant  water,  and  this  part  of  the  city  is  described  as  being  ill  paved,  with 
numerous  collections  of  stagnant  water,  and  abounding  in  every  other  variety 
of  nuisance.  It  was  claimed  by  Potter  (23),  that  no  case  of  yellow  fever  ever 
originated  in  West  Baltimore  above  Hanover  Street,  beyond  the  sphere  of 
exhalation  from  the  docks,  wharves,  and  low  grounds.  The  winds  exerted  a 
definite  influence  upon  the  progress  of  the  spread  of  the  disease,  it  being 
recorded  by  Davidge  and  Potter  that  in  the  epidemic  of  1797,  following  a 
strong  east  wind  (northeast  according  to  Davidge  and  southwest  according  to 
Potter),  the  disease  spread  rapidly  among  the  inhabitants  of  the  upper  part 
of  Frederick,  Gay,  South,  and  Calvert  Streets  and  even  to  the  vicinity  of 
Federal  Hill  on  the  other  side  of  the  basin.  Potter  noted  in  1800  that  the 
increment  of  cases  could  be  calculated  with  tolerable  accuracy  by  observing  the 
variations  of  the  winds.  Reese,  in  his  history  of  the  epidemic  of  1819  which 
began  at  Smith’s  Dock,  Fell’s  Point,  attributed  the  spread  of  the  disease  from  its 
first  circumscribed  limits  to  the  strong  easterly  wind  which  lasted  for  several 
days.  Shortly  after  a  day  of  fasting  and  prayer,  instituted  by  the  mayor  on  peti¬ 
tion  of  the  clergy,  the  wind  veered  suddenly  from  the  southeast  to  the  northwest, 
“  and  blew  with  such  force  from  that  quarter  that  the  basin  was  thoroughly 
washed  out,  a  general  cleansing  of  the  filthy  situation  of  the  docks  was  the 
result,  and  the  evidences,  which  had  been  previously  offered  that  the  disease 
was  progressing  towards  the  healthier  districts  of  the  city,  ceased  to  be  ex¬ 
hibited.”  In  this  connection,  it  should  be  stated  that  Reese  records  that  in  this 
year,  yellow  fever  appeared  at  the  same  date  at  both  the  lazaretto  and  at  Fell’s 
Point.  The  lazaretto  was  some  2  miles  to  the  east  and  south  of  Smith’s  Dock 
at  Fell’s  Point,  and  between  them  were  the  large  filthy  ponds  previously  alluded 
to.  At  or  near  the  same  time  that  the  disease  appeared  at  the  lazaretto  and  at 
Fell’s  Point,  it  prevailed  also  at  Fort  McHenry,  immediately  opposite  the 
lazaretto.  In  the  light  of  our  present  knowledge,  it  is  almost  certain  that  the 
disease  was  commonly  introduced  by  shipping  either  at  the  lazaretto,  where 
ships  first  entered  and  were  detained,  or  at  Fell’s  Point,  where  they  unloaded 
after  passing  the  quarantine.  A  southeasterly  wind  tended  to  blow  mosquitoes 
from  the  lazaretto  and  its  neighborhood  to  Fell’s  Point  and  from  the  Fell’s  Point 
district  to  the  lower  portion  of  the  city  about  the  basin.  A  more  easterly  wind 
passed  over  the  lazaretto  to  Fort  McHenry  at  the  end  of  Whetstone  Point. 
A  northwest  wind  would  blow  mosquitoes  away  from  the  city  towards  Fell’s 
Point  and  from  Fell’s  Point  towards  the  lazaretto  and  over  Whetstone  Point  to 
the  Patapsco  River. 


88 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


It  was  recorded  by  a  number  of  observers,  but  with  particular  emphasis  by 
Potter  and  Reese,  that  the  only  individuals  residing  in  the  higher  parts  of  the 
city  who  developed  yellow  fever  in  these  various  epidemics  were  those  who 
visited  infected  districts,  usually  Fell’s  Point,  at  night.  Davidge,  however, 
records  that  a  considerable  number  of  persons  from  the  higher  parts  of  town 
who  went  to  Fell’s  Point  to  witness  the  launching  of  a  frigate  contracted  yellow 
fever  during  the  epidemic  of  1797.  It  was  emphasized  in  all  records  that  no 
one  developed  yellow  fever  after  contact  with  cases  outside  of  the  yellow-fever 
afflicted  districts  of  the  city.  Davidge  distinctly  stated  that  from  none  of  those 
persons  living  up  town  who  contracted  the  disease  at  the  launching  of  the  frigate 
did  the  disease  spread.  Potter  stated  that  in  not  a  single  instance  was  the  disease 
communicated  to  their  associates  by  those  persons  who,  living  in  the  higher 
parts  of  the  city,  contracted  the  disease  after  visits  to  the  lower  portions  of 
the  city. 

During  these  epidemics,  but  particularly  in  that  of  1819,  great  numbers  of 
people  from  the  infected  districts  were  removed  to  the  higher  portions  of  the 
city  or  to  the  surrounding  country.  Dr.  Allender  and  Dr.  Clendinen  (36), 
are  recorded  as  saying  that  “  those  who  were  seized  with  the  disease  and  removed 
did  not  propagate  it,  nor  was  anyone  infected  from  the  atmosphere  by  those 
who  imbibed  the  poison  at  its  sourse.”  In  1819,  great  numbers  of  yellow-fever 
patients  were  removed  from  Fell’s  Point  to  the  hospital  situated  in  the  high 
portion  of  the  city  on  Broadway  and  Monument  Street,  and  it  was  affirmed  by 
Reese  that  not  a  single  case  of  the  disease  occurred  among  physicians,  nurses, 
or  visitors  to  the  hospital. 

Reese  was  a  strong  adherent  to  the  doctrine  of  the  indigenous  origin  of 
yellow  fever  and  was  thoroughly  convinced  that  the  disease  was  not  contagious. 
He  was,  therefore,  an  emphatic  opponent  of  the  usual  quarantine  system  and 
condemned  the  British  physicians  who  advised  their  Government  that  yellow 
fever  was  highly  contagious,  although  a  case  of  the  disease  had  never  occurred 
on  the  island.  While  recognizing  that  the  local  quarantine  laws  were  so  amelio¬ 
rated  that  Baltimore  did  not  suffer  half  the  inconvenience  and  delays  of  other 
places,  still  he  regarded  the  Baltimore  practices  as  grossly  absurd.  He  pro¬ 
posed  the  following  principles  of  quarantine: 

“  If  a  vessel  arrive  from  a  foreign  port,  where  it  is  known  that  at  the  time  of  her 
departure  the  disease  raged  with  unimpeded  violence,  let  this  vessel  be  examined  by 
the  health  officer ;  the  sick,  if  any,  removed ;  and  if  necessary  the  vessel  be  cleansed  and 
then  suffered  to  proceed  to  her  destination.  This  could  all  be  done  in  forty-eight  hours. 
If,  on  the  contrary,  the  vessel  should  be  found  to  contain  any  vegetables  in  a  state  of 
putrefaction,  or  if  persons  had  been  diseased  and  died  on  the  passage  after  the  vessel 
was  out  at  sea,  then  some  detention  should  take  place;  but  the  healthy  individuals  on 
board  ought  to  be  permitted  to  proceed  to  their  place  of  destination.  This  kind  of 
quarantine  would  be  consistent  with  the  facts,  and  would  prevent  the  importation  of 
any  contagious  disease  more  effectually  than  the  one  at  present  in  vogue.” 

For  another  reason  he  protested  against  quarantine  regulations.  He  held  that 
the  practice  of  detaining  vessels  at  a  lazaretto  12  to  40  days,  in  the  heat  of 
summer,  without  any  cleansing  or  ventilation,  was  calculated  to  effect  what  it 
was  intended  to  prevent.  If  such  vessels  thus  proscribed  contained  coffee  and 
other  substances  liable  to  undergo  putrefaction,  they  would  at  least  be  injured 
by  the  detention,  and  if  they  were  damaged  at  all,  the  lack  of  ventilation  would 
increase  the  damage. 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


89 


“  Such  vessels  are  then  permitted  to  proceed  to  the  center  of  our  cities,  the  hatches 
are  removed,  and  the  gas  evolved  from  their  holds  is  so  fetid  and  poisonous  that  whole 
cities  are  infected  by  the  noxious  vapor  generated  during  the  detention  of  the  vessel; 
and  if  she  had  been  suffered  to  come  up  to  unload  at  once  upon  her  arrival,  no  mischief 
would  have  resulted,  but  much  evil  would  have  been  avoided.” 

He  deprecated  copying  European  authorities  either  in  politics  or  science. 

In  connection  with  the  idea  of  the  indigenous  origin  of  yellow  fever,  Potter 
stated  that  when,  in  consequence  of  the  embargo  on  foreign  commerce  in 
1807,  no  foreign  sail  appeared  in  the  Baltimore  Harbor,  yellow  fever  broke  out 
at  Fell’s  Point. 

These  ideas  were  supported  by  the  opinion  of  the  organized  profession  in  a. 
letter  (36)  signed  by  Dr.  Ashton  Alexander  and  Dr.  John  B.  Caldwell,  secre¬ 
tary  of  the  District  Medical  Society,  written  in  reply  to  a  letter  of  David 
Burke,  chairman  of  the  committee  of  the  city  council  in  charge  of  the  health 
ordinances,  who  had  propounded  seven  questions  concerning  the  causes  of  yellow 
fever  and  its  relation  to  local  conditions.  In  the  letter  referred  to,  Dr.  Alex¬ 
ander  and  Dr.  Caldwell,  after  describing  the  general  sanitary  conditions  of 
Fell’s  Point,  stated  definitely  that,  in  the  opinion  of  the  society,  the  yellow 
fever  of  1819  was  to  be  ascribed  to  the  decomposition  of  vegetable  matters 
about  the  wharves,  in  the  streets,  the  ponds,  and  cellars.  They  explicitly  stated 
that  the  society  did  not  consider  the  putrefaction  of  animal  matters  competent 
to  the  production  of  yellow  fever,  and  that  “  the  doctrines  of  contagion  and 
importation  received  no  countenance  from  this  society.”  They  expressed  belief 
that  the  cause  of  the  disease  may  be  imported,  if  by  this  is  understood  a  cargo 
of  vegetable  substances  in  a  putrescent  state.  They  had  observed  no  differences 
in  the  habits  and  modes  of  living  of  the  people  in  the  infected  district  from 
those  of  the  people  of  the  same  rank  living  in  parts  of  the  city  where  the  disease 
did  not  prevail.  In  regard  to  the  organization  of  the  board  of  health,  they  gave 
it  as  the  opinion  of  the  society  that  it  should  have  at  least  one  medical  member 
with  whom  to  hold  counsel  and  to  whom  they  might  refer  on  points  touching 
the  health  of  the  city.  They  recommended  that  the  quarantine  regulations 
should  be  strictly  enforced  in  all  cases  where  the  cargoes  were  damaged  or  the 
vessel  in  a  foul  state,  until  a  change  of  conditions  would  safely  permit  her 
entrance  into  the  port,  but  this  recommendation  was  not  intended  to  deprive  the 
passengers  or  crew  of  the  privilege  of  free  communication  with  the  city. 

These  recommendations  ended  in  a  complete  recasting  of  the  health  depart¬ 
ment,  and  the  new  health  ordinance  of  February  29,  1820,  framed  after  the  last 
great  yellow-fever  epidemic,  under  the  influence  of  the  Medical  Faculty  and 
under  the  mayoralty  of  Dr.  Edward  Johnson,  a  leading  physician,  contained 
no  quarantine  provisions. 

In  the  light  of  the  foregoing,  it  is  well  rapidly  to  review  the  correlation 
between  these  ideas  and  the  quarantine  regulations  and  practices  of  Baltimore. 
From  the  above  facts,  quoted  from  contemporary  literature,  and  from  a  con¬ 
sideration  of  the  health  ordinances,  it  is  clear  that  the  early  quarantine  regula¬ 
tions  and  practices  were  determined  by  the  ideas  held  concerning  the  etiology 
and  mode  of  transmission  of  yellow  fever.  The  ordinances  of  1797  provided  a 
10-day  quarantine  on  ships  and  their  personnel,  arriving  from  beyond  the  seas 
and  “  all  other  suspected  places,”  only  during  the  months  between  April  1  and 
October  1  (the  yellow-fever  season),  and  gave  the  health  authorities  power  to 


90  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

interdict  the  landing  of  damaged  coffee,  hides,  or  other  damaged  material — 
substances  from  which  it  was  believed  the  cause  of  yellow  fever  might  arise. 

Four  years  later,  in  1801,  the  quarantine  restrictions  were  limited  to  vessels 
from  both  the  Indies,  Africa,  South  America,  the  Mediterranean,  and  connected 
waters  east  of  Gibraltar,  and  the  ports  of  the  western  coast  of  Spain,  as  far  as 
Cape  St.  Vincent,  but  only  between  May  1  and  November  1.  The  primary 
quarantine  period  was  3  days,  with  extension  by  an  additional  10  days,  at  the 
discretion  of  the  quarantine  officer.  Vessels  from  such  ports  were,  however, 
required  to  discharge  cargoes  and  ballast  at  the  quarantine  station,  and 
ventilation  of  the  ship  and  wearing  apparel  of  persons  on  board  was  enforced. 
Vessels  loaded  with  coffee  (from  West  Indian  or  other  ports),  arriving  between 
June  1  and  October  1,  could  discharge  cargoes  into  lighters  instead  of  at  the 
quarantine  station.  Under  both  ordinances,  the  sick  on  vessels  were  sent  to 
the  hospital  at  Hawkins’  Point.  The  restriction  of  the  quarantine  season  to 
the  four  or  five  hot  months,  the  short  duration  of  detention,  and  the  mildness 
of  the  regulations  in  regard  to  ships,  goods,  clothing,  and  persons,  and  the  total 
abandonment  of  all  quarantine  regulations  between  1808  and  1821  prove  that 
the  quarantine  system  was  directed  against  yellow  fever  especially,  rather  than 
against  plague,  small-pox,  typhus  fever,  or  other  diseases.  It  is  to  be  noted  that 
when  the  health  ordinances  were  entirely  recast  in  1820,  when  by  common 
consent  yellow  fever  was  regarded  as  of  local  origin  and  not  contagious,  all 
provisions  for  quarantine  of  the  port  were  omitted.  The  very  liberal  quarantine 
laws  revived  in  1821  and  expanded  in  1823,  while  still  stressing  the  impor¬ 
tance  of  materials,  provided  for  the  examination  of  persons  and  prepared  the 
way  for  the  more  stringent  investigation  of  persons,  both  crew  and  passengers, 
made  mandatory  in  the  revised  health  ordinance  of  1826.  The  latter  and 
various  successive  ordinances  left  general  details  of  the  quarantine  system  to 
the  quarantine  officer  and  the  board  of  health.  By  1826,  the  tide  of  immigra¬ 
tion  to  Baltimore  from  Europe,  which  had  set  in  after  the  close  of  the 
Napoleonic  wars,  had  reached  a  high  point,  and  it  was  to  protect  the  city 
against  small-pox  and  typhus  fever  likely  to  be  brought  in  by  these  immigrants 
that  the  quarantine  system  was  revived  in  its  new  form.  So  far  as  yellow  fever 
is  concerned,  the  Baltimore  authorities  prided  themselves  that  they  never 
instituted  quarantine  against  any  port  on  account  of  that  disease,  and  they 
sharply  criticized  Alexandria,  Virginia,  for  imposing  quarantine  restrictions 
upon  Baltimore  for  that  reason.  During  the  severe  epidemics  of  this  disease 
at  Norfolk,  Portsmouth,  and  Gosport,  Virginia,  in  1855,  Baltimore  kept  up 
active  trade  with  her  stricken  sisters,  and  welcomed  their  refugees  in  large 
numbers.  So  convinced  were  the  Baltimore  authorities  of  the  unwisdom  of  a 
stringent  quarantine  system  that,  in  1830,  Dr.  Horatio  G.  Jameson,  the  con¬ 
sulting  physician  of  the  health  department,  went  to  an  international  meeting 
of  hygienists  in  Hamburg  with  the  purpose  of  inducing  continental  authorities 
to  modify  their  quarantine  regulations  to  conform  with  those  of  Baltimore. 
In  1832,  when  an  invasion  of  cholera  was  imminent,  Dr.  Jameson  held  that  this 
disease  is  not  contagious  and  that  restrictive  measures  should  not  be  attempted. 
Though  the  mayor  agreed  with  him,  on  account  of  opposition  on  the  part  of 
the  council  and  the  public,  they  were  unable  to  act  consistently  with  this 
doctrine. 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


91 


On  account  of  the  lack  of  the  reports  of  the  health  officer  or  quarantine 
physician  before  1827,  it  is  not  possible  to  review  with  any  accuracy  adminis¬ 
trative  practices  of  this  official  under  the  quarantine  laws  before  this  date. 
It  is  probably  correct  to  assume  that  he  carried  out  the  spirit,  if  not  the  letter 
of  the  ordinances  which  obtained.  It  will  be  recalled  that  by  the  ordinances 
of  1823  and  of  1826,  the  quarantine  was  reestablished  with  the  retention  of 
the  better  features  of  the  old  laws,  and  that  by  the  late  ordinances  the  health 
officer,  under  the  commission  of  health,  was  to  determine  whether  and  to  what 
degree  quarantine  should  be  imposed  on  coastwise  and  foreign  vessels. 

All  vessels  were  required  to  anchor  at  the  quarantine-ground  for  examination 
of  the  passengers,  crew,  and  cargo.  The  health  officer  passed  them  at  his 
discretion.  Vessels  that  he  held  for  quarantine  were  sent  to  the  lazaretto  for 
cleaning  and  for  the  discharge  of  cargoes  and  passengers.  Private  vessels  and 
vessels  with  more  than  15  passengers,  arriving  from  sea  were  required  to  land 
their  ballast  and  empty  and  cleanse  their  water  casks  at  the  lazaretto  wharf. 
Their  timbers  were  inspected  by  the  health  officer  before  the  vessels  were  per¬ 
mitted  to  come  to  any  wharf  within  the  limits  of  the  city. 

As  a  matter  of  practice,  as  shown  by  the  annual  reports  of  the  quarantine 
officer  since  1827,  it  had  been  the  custom  to  retain  at  quarantine  cases  of  yellow 
fever,  cholera,  small-pox,  typhus  fever,  and  occasionally  scarlet  fever,  measles, 
and  malarial  fever  from  incoming  ships,  and  in  case  of  small-pox  on  board  to 
vaccinate  everyone,  both  crew  and  passengers,  and  to  pass  the  ship  after  dis¬ 
infection.  The  methods  of  disinfection  included  removal  of  the  whole  cargo 
and  airing  it  at  the  Lazaretto,  cleaning  and  washing  the  ship,  and  the  use  of 
various  disinfectants. 

As  an  indication  of  the  amount  of  work  entailed  during  the  quarantine 
period  of  1827,  there  were  546  ships,  of  which  177  were  from  foreign  ports  and 
carried  1,429,  out  of  a  total  of  1,688  passengers.  In  1829,  4,600  passengers 
were  inspected  by  the  health  officer.  From  1827  to  1834  it  was  recorded  that 
the  health  officer  examined  44,821  passengers,  of  whom  40,973  were  foreigners. 

The  clothing  of  those  sick  with  small-pox,  or  typhus  or  yellow  fever,  was 
usually  sunk  or  burned,  but,  for  a  while  at  least,  it  was  passed  after  being 
well  aired. 

The  health  officer  made  frequent  comments  upon  the  condition  of  immigrant 
passengers.  In  1829,  he  states  that  the  passage  money  of  many  of  the  immi¬ 
grants  was  provided  by  the  parish  from  which  they  came.  He  often  remarked 
upon  the  destitute  and  filthy  condition  of  the  immigrants  and  upon  their  cor¬ 
poreal  and  mental  disabilities,  which  caused  the  assignment  of  many  of  them 
to  the  Baltimore  almshouse.  In  1837  he  estimated  “  that  75  per  cent  of  the 
immigrants  included  the  halt,  lame,  blind,  mendicants,  and  persons  unac¬ 
quainted  with  any  kind  of  business  except  laboring.”  Many  of  the  immigrants 
at  this  time  were  Irish  and  German. 

Ships  from  infected  ports  were  passed  if  the  personnel  was  healthy,  the 
ships  clean,  and  the  cargoes  without  damaged  goods.  “  Damaged  goods  ”  were 
those  that  showed  evidences  of  spoiling  and  putrefaction,  chiefly  coffee  and 
hides,  and  they  were  aired  at  the  lazaretto  before  being  brought  to  the  city. 
Until  the  goods  were  submitted  to  this  process  for  an  uncertain  period  they 
were  not  allowed  to  be  brought  to  the  city.  The  health  officers  were  greatly 


4 


92  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

exercised  over  the  foul  condition  of  the  holds  of  vessels  and  apparently  had 
more  trouble  with  coastwise  than  with  foreign  vessels  on  this  account.  In 
1829,  Dr.  Samuel  B.  Martin,  the  health  officer,  reported  much  benefit  in 
cleaning  the  holds  of  vessels  from  the  use  of  “  chlorine  in  combination  with 
lime.”  This  is  the  only  mention  made  of  the  use  of  a  particular  disinfectant, 
but  it  is  probable  that  lime  was  most  commonly  used  for  this  purpose. 

These  practices  were  enforced  with  little  modification  until  1847.  The 
reports  of  the  health  officers  during  this  period  indicate  that  careful  examina¬ 
tions  of  crew  and  passengers  were  carried  out  routinely,  particularly  for  small¬ 
pox,  typhus  fever,  and  yellow  fever,  as  well  as  for  cholera  during  epidemics  of 
that  disease.  One  of  the  practices  early  established  was  that  of  vaccinating 
both  passengers  and  crew  when  a  ship  was  held  for  either  small-pox  or  typhus 
fever.  No  indication  is  given  as  to  how  long  ships  with  infected  passengers  were 
held  or  for  how  long  a  period  well  persons  on  infected  ships  were  quarantined. 
The  sick  were  removed  at  once  to  whatever  hospital  accommodations  were 
available. 

It  does  not  appear  from  the  records  when  removal  and  airing  of  cargoes  and 
the  cleansing  of  vessels  were  stopped.  The  abandonment  of  these  practices 
apparently  coincided  with  the  adoption  of  uniform  quarantine  plans  for  all 
ports,  under  the  general  direction  and  with  the  co-operation  of  the  United 
States  Marine  Hospital  Service  and  its  successor,  the  United  States  Health 
Service  after  1880. 

Throughout  the  history  of  the  quarantine  service,  both  before  and  after  its 
modifications  to  conform  in  a  general  way  with  the  restrictions  and  methods 
advocated  by  the  Federal  Government  through  the  Marine  Hospital  and 
Public  Health  Services,  it  has  been  the  practice  of  the  health  department  to 
hold  at  the  quarantine  station  discovered  cases  of  small-pox,  typhus  fever, 
yellow  fever,  cholera,  and  severe  cases  of  malaria. 

THE  LAZARETTO  AND  HOSPITAL  FACILITIES  IN  CON¬ 
NECTION  WITH  THE  QUARANTINE  PORT. 

Baltimore  City  inherited  from  Baltimore  Town  a  small  quarantine  hospital, 
the  construction  of  which  had  been  authorized  by  the  legislature  at  the  time 
of  the  yellow-fever  epidemic  in  1794.  It  was  situated  at  Hawkins5  Point,  on 
the  southern  shore  of  the  Patapsco,  due  west  across  the  river  from  Sparrow’s 
Point  and  Fort  Carroll,  about  4.5  miles  due  south  from  Fort  McHenry,  and 
about  3.5  miles  southwest  from  the  Lazaretto  Light.  It  was  probably  reached 
only  by  boat.  There  is  no  record  of  the  number  of  patients  with  yellow  fever 
or  other  diseases  that  were  accommodated  there.  It  was  completely  under  the 
jurisdiction  of  the  Baltimore  Health  Department  and  was  probably  in  use 
until  1830.  In  that  year  arrangements  were  made  with  the  Director  of  the 
United  States  Marine  Hospital  Service  in  Baltimore  to  have  the  most  com¬ 
fortable  part  of  the  lazaretto  fitted  up  with  plain  accommodations  for  the 
reception  of  cases  of  contagious  diseases  arriving  on  ships.  The  lazaretto  for 
the  reception,  airing,  and  cleansing  of  goods  taken  from  ships  was  owned  by  the 
United  States  Government  and  was  established  shortly  after  1801  at  Lazaretto 
Point,  about  2  miles  southeast  of  Fell’s  Point,  just  across  the  river  from 
Fort  McHenry,  and  at  the  junction  of  the  southern  and  eastern  boundary  lines 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


93 


of  the  city  as  they  existed  from  1816  to  1919.  It  is  probable  that  the  health 
officer  boarded  ships  from  the  lazaretto  until  180?,  when  his  office  was  estab¬ 
lished  at  Fort  McHenry.  The  lazaretto  was  a  large  quadrangular  building,  but 
there  are  no  plans  extant,  giving  the  size  and  plan  of  the  lazaretto  buildings 
and  wharves. 

The  first  lazaretto  was  destroyed  by  fire  in  1836.  The  Marine  Hospital 
Service  apparently  had  no  hospital  for  sailors  sick  with  ordinary  diseases  until 
recent  years.  For  many  years,  at  least,  they  were  evidently  sent  to  different 
hospitals  in  the  city. 

About  1845  there  was  constructed  by  the  city  a  new  quarantine  station  of 
considerable  size,  called  the  Marine  Hospital.  It  was  situated  at  what  is  now 
known  as  Fairfield,  on  the  southern  shore  of  the  Patapsco  River,  about  1.25 
miles  directly  south  of  Fort  McHenry.  This  hospital,  while  designed  primarily 
to  accommodate  sick  immigrants,  was  provided  with  additional  accommodations 
to  be  used  as  a  pest-house  chiefly  for  cases  of  small-pox  and  typhus  fever  from 
the  city.  It  is  evident  that  the  accommodations  at  the  pest-house  were  at  times 
insufficient  to  accommodate  all  the  cases  of  typhus  fever  taken  from  vessels  at 
quarantine,  for  Thomas  H.  Buckler  records  that  in  1847  some  of  the  first  cases 
of  typhus  fever  brought  by  the  ship  Rio  Grande  were  sent  to  the  medical  wards 
of  the  Baltimore  City  and  County  almshouse  and  that  with  the  repeated  arrival 
of  immigrant  ships  with  cases  of  the  disease,  these  wards  were  filled  with 
typhus  cases  in  the  course  of  a  few  weeks.  The  name,  Marine  Hospital,  was  a 
misnomer,  for  it  was  not  a  hospital  for  mariners,  but  for  immigrants,  as  well 
as  a  pest  hospital  for  the  city.  It  is  probable  that,  at  times  at  least,  sailors  with 
communicable  diseases  were  received  there.  For  some  years  this  hospital  was 
under  the  charge  of  a  resident  physician,  but  later  the  health  officer  or  quaran¬ 
tine  officer  was  given  charge  of  it. 

It  appears  that  during  the  Civil  War  the  United  States  Government  erected 
a  flimsy  barrack  hospital  on  these  grounds,  and  after  the  war  this  structure 
was  taken  over  by  the  city  as  a  pest  hospital. 

In  1881,  the  quarantine  station  was  moved  to  Leading  Point,  about  8  miles 
below  Fort  McHenry.  Here  two  wooden  structures  were  erected,  one  for  sailors 
and  passengers  with  contagious  diseases  and  the  other,  a  large,  barrack-like 
structure,  as  a  pest-house  for  the  city.  In  connection  with  the  hospital  there  is 
a  large  steam  disinfecting  plant. 

Both  the  old  Marine  Hospital  and  the  quarantine  station  at  Leading  Point 
were  best  reached  from  the  city  by  water.  The  road  to  the  former  was  always 
excreable  and  that  to  the  latter,  until  recently,  was  rough. 

THE  EFFECTIVENESS  OF  MARITIME  QUARANTINE. 

As  will  appear  very  clearly  in  the  separate  studies  of  the  course  of  various 
epidemic  diseases,  the  quarantine  station  of  the  Port  of  Baltimore  did  not, 
until  very  recent  years,  at  least,  offer  a  very  efficient  barrier  to  the  ingress  of 
certain  diseases,  epidemic  waves  of  which  have  repeatedly  broken  over  the  city. 

In  nearly  every  year  between  1794  and  1807,  the  period  of  most  stringent 
quarantine  laws,  there  were  larger  or  smaller  epidemics  of  yellow  fever.  In 
the  latter  year,  owing  to  an  embargo  on  shipping,  no  foreign  vessels  entered 
the  port.  In  1793  there  was  a  large  immigration  from  San  Domingo,  but  no 


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PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


cases  of  yellow  fever  were  recognized  in  the  city.  These  immigrants  arrived  at 
the  time  when  the  local  quarantine  was  under  the  State  officials.  Within  the 
next  20  years,  partly  on  account  of  this  immigration,  there  was  a  great  increase 
in  trade  with  the  West  Indies,  and  particularly  with  San  Domingo.  Although 
between  1807  and  1821  there  were  no  quarantine  laws  in  force,  yellow  fever 
was  recorded  in  Baltimore  only  in  1819  and  1821.  From  1812  to  the  spring  of 
1815,  shipping  was  to  some  degree  interf erred  with  on  account  of  the  war. 

The  reports  of  the  quarantine  officer  are  available  from  1827.  These  contain 
no  records  of  the  detention  of  cases  of  yellow  fever  until  1848,  when  there  was 
1  case.  Between  1848  and  1900,  a  period  of  52  years,  there  were  removed  from 
vessels  a  total  of  83  cases  of  yellow  fever,  28  of  which  were  detained  in  the  5- 
year  period  1855-1859.  The  largest  number  of  cases  detained  in  a  single  year 
was  12,  in  1855;  10  cases  were  detained  in  1870;  6  cases  in  1857  and  1884;  5 
cases  in  1859,  1873,  and  1877;  4  cases  in  1856,  1874,  and  1894;  3  cases  in 
1891;  and  2  cases  in  1849,  1853,  1872,  1875,  1879,  and  1897.  In  nine  other 
years  there  were  single  cases.  In  1853,  when  2  cases  were  detained  at  quaran¬ 
tine,  there  were  18  fatal  cases  in  the  city,  and  in  1859,  when  5  cases  were  taken 
from  vessels,  5  cases  occurred  within  the  city.  It  is  of  special  interest  that  in 
1855,  with  12  cases  at  quarantine,  there  were  13  deaths  from  the  disease  in 
the  city,  occurring  among  refugees  from  the  cities  at  the  mouth  of  the  Chesa¬ 
peake  Bay,  but  from  none  of  these  cases  did  secondary  cases  arise.  Cases  of 
the  disease  were  detained  each  year  at  quarantine  from  1872  to  1881,  inclusive. 
It  is  not  known,  of  course,  how  many  cases  occurred  within  the  city  among 
individuals  passed  at  quarantine. 

After  1831  there  was  a  drop  in  the  West  Indian  trade,  but  a  gradual  increase 
in  shipping  from  South  American  ports. 

Though  it  is  certain  that  typhus,  jail,  or  ship  fever  was  early  included  among 
the  “  pestilential  diseases  ”  by  the  local  health  department,  the  records  of  the 
quarantine  officer  made  no  mention  of  detained  cases  of  this  disease  before  1845. 
The  tables  of  interments,  however,  show  that  deaths  from  typhus  fever  occurred 
in  the  city  every  year  from  as  early  as  1813  at  least  until  1861,  and  that  this 
disease  was  the  cause  of  a  considerable  number  of  deaths  in  1814-1815,  1818- 
1820,  1823-1824,  and  1847-1850.  (See  Table  17.)  Since  cases  of  typhus  fever 
and  small-pox,  originating  within  the  city,  had  been  sent  to  the  marine  or 
quarantine  hospital  by  1845,  it  is  impossible  to  determine  what  proportion  of 
the  cases  recorded  at  the  station  were  taken  from  ships.  However,  during  the 
time  of  the  great  Irish  immigration  beginning  in  1847,  a  considerable  number 
of  cases  were  recorded  at  the  quarantine  hospital :  101  in  1847,  14  in  1848, 
140  in  1849,  6  (all  said  to  have  come  from  the  city)  in  1850,  10  in  1851,  54  in 
1852,  30  in  1853,  23  in  1854,  and  6  in  1855.  Only  3  cases  of  typhus  fever  were 
recorded  between  1857  and  1869 :  2  in  1857  and  1  in  1866.  In  1870  there 
were  282  cases,  and  in  1871,  17,  probably  most  of  them  from  the  city.  Since 
this  date  there  have  been  a  few  cases  recorded  in  occasional  years. 

In  only  a  few  years  between  1850  and  1919  were  there  no  cases  of  small-pox 
recorded  at  the  quarantine  station  or  its  hospital.  However,  as  from  the  earliest 
times  cases  of  this  disease  were  sent  from  the  city  to  whatever  hospital  existed 
in  connection  with  the  station,  it  is  not  possible  to  estimate  what  proportion 
of  the  recorded  cases  represent  cases  removed  from  vessels.  In  the  older  reports, 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


95 


from  1827  to  1847,  specific  mention  is  made  of  removal  of  cases  from  vessels, 
as,  for  instance,  2  cases  in  1827,  1828,  and  1831,  respectively,  “  several 
cases  ”  in  other  years,  16  cases  in  1836,  and  30  cases  in  1837.  Often  the  name 
and  nationality  of  the  vessel,  usually  German  from  Bremen,  is  given.  After 
1845,  when  a  ward  of  20  beds  was  provided  for  small-pox  patients  at  the 
Marine  Hospital,  considerable  numbers  of  cases  are  known  to  have  been  sent 
from  the  city,  and  in  some  years  the  number  of  such  cases  is  given.  These 
years  mark  the  known  epidemic  years  of  small-pox  in  the  city.  In  some  of 
these  years  the  cases  numbered  hundreds. 

Cases  of  cholera  are  recorded  as  having  been  removed  from  vessels  only 
twice,  once  each  in  1850  and  1866.  Cases  of  cholera  were  looked  for  by  the 
quarantine  officer  in  1832,  the  great  cholera  year,  but  none  were  discovered  on 
ships  entering  the  port. 

After  1847,  malaria,  typhoid  fever,  and  occasionally  scarlet  fever  and  measles 
are  mentioned.  Though  not  stated  in  the  reports,  it  is  a  well-attested  fact 
that  the  authorities  permitted  large  steamship  companies  to  enter  into  contracts 
with  general  hospitals  in  the  city  to  receive  cases  of  scarlet  fever,  measles,  and 
diphtheria  from  their  vessels,  and  that  there  was  a  competition  between  at  least 
three  such  hospitals  for  these  contracts.  The  city's  hospital  facilities  at  quar¬ 
antine  were,  and  are  yet,  hopelessly  inadequate  to  accommodate  more  than  a 
few  such  cases.  Indeed,  until  very  recently,  no  attempt  was  ever  made  to  pre¬ 
vent  the  importation  of  cases  of  these  diseases  directly  into  the  city.  Before 
1850  they  were  not  regarded  as  “  pestilential  diseases.”  As  late  as  1893  it  was 
not  unusual  for  one  of  these  general  hospitals  to  receive  as  many  as  a  hundred 
cases  of  measles  from  a  single  North  German  Lloyd  immigrant  steamer. 

In  regard  to  typhus  and  typhoid  fevers,  small-pox,  measles,  scarlatina,  diph¬ 
theria,  influenza,  and  probably  cholera,  the  dispassionate  student  is  forced  to 
the  conclusion  that  the  quarantine  system,  as  applied  at  the  port  of  Baltimore 
and  at  other  Atlantic  seaports,  until  recently  was  futile.  In  1851,  Thomas  H. 
Buckler  (11)  pointed  out  that  in  1847  typhus  fever  was  diffused  throughout  the 
city  by  Irish  immigrants  who  were  passed  by  the  quarantine  authorities,  and 
he  severely  criticized  the  quarantine  facilities  and  methods  of  the  port  as 
inadequate.  Many,  if  not  most,  of  the  severe  European  epidemics  of  these 
diseases  have  been  reflected  in  Baltimore.  No  quarantine  system  has  kept 
them  out  of  some  port,  and,  having  visited  the  country,  they  have  spread  to 
Baltimore  through  her  otherwise  open  portals  if  not  through  the  only  partly 
closed  door  of  the  quarantine  station.  That  at  times  a  few  cases  of  one  or 
another  of  these  diseases  have  been  kept  from  entering  by  this  portal  may  be 
assumed. 

It  is  very  probable  that  since  1845  the  maritime  quarantine  has  served  a 
good  purpose  in  preventing  the  ingress  of  cases  of  the  severer  types  of  malarial 
fever  from  Central  and  South  America.  This  is  counterbalanced,  however, 
by  the  fact,  attested  by  the  quarantine  physicians,  that  many  patients  with 
small-pox  and  typhus  fever  sent  from  the  city  to  the  old  Marine  Hospital  died 
of  malarial  fevers  contracted  there. 

A  fair  evaluation,  at  this  late  date,  of  the  efficacy  of  the  quarantine  in  pre¬ 
venting  epidemics  of  yellow  fever  in  Baltimore  is  almost  impossible.  The  facts 
must  be  faced  that  during  the  early  years  of  most  active  quarantine  the  disease 
was  prevalent  in  epidemic  form  nearly  every  year;  that  when  the  quarantine 


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was  done  away  with,  it  occurred  but  twice  in  16  years;  that  after  the  quaran¬ 
tine  was  reestablished  in  1821,  though  cases  of  the  disease  are  known  to 
have  existed  in  the  city  on  several  occasions,  it  has  never  spread  generally ;  and 
that  moreover,  in  some  years  when  no  cases  were  detained  at  quarantine,  the 
disease  broke  out  in  the  city,  as,  for  instance,  in  1854,  when  over  40  cases 
occurred  at  Fell’s  Point.  Stegomyia  mosquitoes,  which  must  have  been  present 
in  the  lower  parts  of  the  city  as  late  as  1821,  could  hardly  have  been  done  away 
with  by  the  unconscious  and  incomplete  anti-mosquito  work  of  that  date. 
The  most  reasonable  explanation  is  that  quite  fortuitously  those  yellow-fever 
patients  who  did  get  into  the  city,  in  1855  for  instance,  did  not  go  to  the  lower 
portions  of  the  city  at  Fell’s  Point  and  the  basin  near  J ones  Falls.  It  is  more 
than  likely  that,  until  late  years,  chance,  rather  than  art,  has  controlled  this 
situation. 

In  regard  to  bubonic  plague,  little  need  be  said,  for  history  shows  that  this 
disease  has  never  been,  at  least  not  until  recently,  a  menace  at  Atlantic  ports, 
any  more  than  at  British  ports  during  the  same  period.  Until  the  last  part  of 
the  nineteenth  century  the  disease  had  not  migrated  to  Europe  or  to  America 
for  centuries,  and  since  that  time  it  would  appear  that  when  it  approached  a 
port  it  has  often  entered  despite  quarantine.  Even  when  it  has  gained  admis¬ 
sion  and  has  spread  widely  among  rodents,  as  in  San  Francisco  and  New 
Orleans,  the  disease  has  never  attacked  man  in  grave  epidemic  form.  It  seems 
that  the  immunity  of  western  Europe  and  of  America  to  deadly  epidemic  plague 
since  the  seventeenth  century  is  to  be  explained  by  the  natural  history  of  the 
disease  rather  than  by  man’s  precautionary  efforts.  No  one  who  is  familiar 
with  what  is  known  of  the  natural  history  of  this  disease  can  entertain  the 
idea  that  the  quarantine  system  of  Baltimore,  at  least  before  1900,  could  have 
possibly  afforded  any  protection  against  its  invasion. 


Chapter  VI. — Public  Health  Administration 

within  the  City. 


I.  Introduction:  Developments  and  accomplishments  of  public  health 
practice  in  the  nineteenth  century,  based  upon  ideas  and  methods  long 
existent  and  determined  very  largely  by  the  more  general  diffusion  of 
knowledge  and  wealth  among  peoples  of  intellectual  and  personal  freedom; 
Influence  of  modern  micro-parasitology;  Reasons  for  vigorous  attacks  on 
nuisances  rather  than  on  contactive  diseases. 

II.  Measures  of  nuisance  prevention  and  abatement  directed  against 
nuisance-borne  diseases :  Definition  of  nuisance ;  Prevention  and  abate¬ 
ment  of  nuisances  on  public  property — Dredging  and  filling;  Grading  and 
paving;  Street  cleaning  and  garbage  removal;  Sewerage;  Water;  Food; 
Prevention  and  abatement  of  nuisances  on  private  property — Standing 
water;  Organic  matter;  Manufactories;  Habitations. 

III.  Measures  of  restriction  directed  against  contagious  diseases: 
Isolation,  inoculation  and  disinfection.  (Tables  4  to  6.) 

INTRODUCTION. 

It  is  customary  to  date  the  beginning  of  modern  public-health  administra¬ 
tion  and  practice  in  municipalities  from  about  the  middle  of  the  nineteenth 
century  and  to  attribute  the  general  sanitary  reforms  which  were  actively 
undertaken  at  this  time  in  certain  European  and  American  cities  to  newly 
acquired  knowledge.  And  especially  is  it  the  habit  to  ascribe  to  advancing 
knowledge  in  micro-parasitology  the  more  vigorous  efforts  to  control  disease 
by  measures  of  general  sanitation  and  of  personal  control  which  have  been 
made  during  the  past  40  or  50  years.  It  is,  however,  a  great  mistake  to  suppose 
that  these  activities  had  their  origin  directly  in  any  very  essentially  new  knowl¬ 
edge  discovered  by  the  generation  by  which  they  were  undertaken.  The  final 
establishment  upon  a  firm  basis  of  the  ancient  germ  theory  of  the  causation  of 
the  febrile  diseases  did  not  in  principle  add  nearly  so  much  to  the  methods 
available  for  preventing  the  spread  of  these  diseases  through  communities  or 
from  place  to  place  as  those  ignorant  of  history  have  assumed  to  be  the  case. 
While  the  newly  acquired  knowledge  changed  reasons  assigned  for  the  employ¬ 
ment  of  certain  measures,  it  did  not  modify  methods  of  practice  in  any  very 
fundamental  manner.  Tactics  rather  than  strategy  were  modified,  but  neither 
was  greatly  enriched,  so  far  as  the  typically  contactive  diseases  are  concerned, 
to  a  degree  that  can  be  called  revolutionary.  It  is  so  widely  believed  and  taught 
that  the  decrease  in  incidence  and  in  mortality  of  so  many  of  the  acute  and 
chronic  febrile  diseases  in  western  civilization  has  been  due  solely  to  the  appli¬ 
cation  of  new  methods  of  sanitation  and  of  personal  control  based  upon  the 
wonderful  advances  in  our  knowledge  of  micro-parasitology  within  the  past 
50  years,  that  it  is  well  at  this  point  to  submit  this  claim  to  critical  analysis. 

In  the  first  place,  the  beneficial  influence  of  an  abundance  of  pure  water 
for  drinking  and  bathing,  of  surface  and  sanitary  sewerage,  of  sanitary  latrines 
for  the  disposal  of  human  dejecta,  and  of  well-paved  and  well-cleaned  streets 
upon  the  public  health  and  comfort  was  well-known  to  the  ancients.  The 

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Romans,  especially,  brought  these  measures  to  a  high  degree  of  perfection, 
and  their  practices  in  these  respects  became  well  known  to  students,  at  least, 
with  the  revival  of  the  study  of  classical  literature  during  and  after  the 
Renaissance.  The  Romans  set  up  a  health  department,  effectual  so  far  as 
matters  of  general  sanitation  are  concerned,  under  the  administrative  charge 
of  the  agdiles,  with  district  physicians  who  attended  the  poor  and  were  on  the 
outlook  for  epidemic  diseases.  A  similar  system  was  revived  in  certain  Italian 
cities,  notably  Venice,  in  the  fifteenth  century.  According  to  Manzoni  (37), 
before  the  plague  epidemic  of  1630  Milan  had  a  permanently  organized  board 
of  health,  with  physicians  among  its  members  and  with  lazarettos  for  the 
isolation  of  the  sick.  It  will  be  recalled  that  the  quarantine  system  of  the 
Mediterranean  ports  was  elaborately  organized  in  the  seventeenth  and  eighteenth 
centuries.  On  Mead’s  advice  this  system  was  copied  in  England  for  emergencies 
in  1720.  Mead’s  (14)  “  recommendations  ”  for  the  control  of  the  spread  of 
the  plague  in  England  embodied  all  the  essential  principles  of  restriction  of 
contactive  diseases  by  measures  directed  to  the  control  of  persons  and  their 
immediate  contactive  environments  in  use  at  the  present  day.  The  fundamental 
importance  of  Mead’s  recommendations  is  evident  from  the  following  synopsis : 

1.  Local  health  councils  with  physicians  and  magistrates  among  the  members 
should  be  established  and  exercise  full  authority. 

2.  Physicians  should  be  employed  to  search  out  cases  and  a  reward  offered  to  the 
person  reporting  the  first  case  in  a  community. 

3.  When  cases  of  the  disease  are  found  in  households  or  elsewhere,  the  sick  should 
be  separated  from  the  sound,  by  removing  the  former,  preferably  at  night,  to 
clean  and  airy  habitations  3  or  4  miles  out  of  town  (hospitalization),  and  given 
every  care  and  attention. 

4.  The  sound  in  such  households  should  be  well  washed  and  shaved  and  given 
fresh  clothes  before  removal  to  lazarettos  for  observation.  The  clothes  previously 
worn  should  be  burned  or  buried. 

5.  All  the  goods  within  houses  from  which  the  sick  are  taken  should  be  buried. 
The  houses  should  be  either  demolished,  or  else  thoroughly  cleaned  and  replastered, 
and  fumigated  with  vinegar  or  sulphur. 

6.  The  bodies  of  the  dead  should  be  buried  deeply. 

7.  Those  attendant  upon  the  sick,  while  near  the  latter,  should  not  draw  in  their 
breath  nor  swallow  their  saliva,  but  should  frequently  wash  the  mouth  and  nose 
with  a  solution  of  vinegar. 

8.  Healthy  inhabitants  who  could  afford  it  should  be  allowed  to  leave  the  town, 
after  undergoing  a  period  of  detention  in  isolated  detention  camps  for  20  days. 

9.  Assemblages  of  people  should  not  be  allowed,  and  beggars  and  idlers  should 
be  confined. 

10.  Proper  authorities  should  see  that  the  houses  of  the  poor  are  kept  clean 
and  sweet.  Whenever  an  overcrowded  condition  is  discovered,  some  of  the  dwellers 
should  be  removed  to  other  quarters. 

11.  Streets  should  be  washed  clean  and  kept  free  of  carrion  and  other  nuisances. 
Laystalls  should  not  be  too  near  the  city. 

12.  Lines  should  be  cast  about  infected  towns,  and  guards  should  prevent  persons 
from  passing  to  other  places  until  they  have  performed  a  quarantine  of  20  days 
under  suitable  precautions.  All  travelers  should  have  certificates.  No  material 
considered  retentive  of  infection  should  be  passed  through  the  lines. 

13.  All  the  expenses  incurred  should  be  borne  by  the  public. 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


99 


These  measures  against  plague,  advised  by  Mead,  and  evidently  largely  bor¬ 
rowed  from  Italy,  have  been  given  the  credit  of  checking  the  spread  of  the  dis¬ 
ease.  They  were  applicable,  and  doubtless  were  applied,  to  other  epidmic  dis¬ 
eases,  and  provision  for  such  application,  in  part  at  least,  to  Baltimore  was  made 
in  the  earliest  health  ordinances.  In  regard  to  the  typically  contagious  diseases, 
these  regulations  were  equally  applicable,  whether  it  be  held  that  these  affec¬ 
tions  are  caused  by  emanations  of  unorganized  form  from  the  bodies  of  the 
sick,  or  by  contagia  viva,  or  micro-parasites.  Whichever  the  true  explanation 
of  their  causation,  separation  of  the  sick  from  the  well,  avoidance  of  contact 
with  the  sick  and  the  articles  of  their  contactive  environment,  the  destruction 
of  these  articles  by  fire  or  their  purification  by  chemicals,  ventilation,  and 
sunlight,  have  been  and  yet  remain  standard  procedures.  The  necessity  of  early 
notification  of  the  occurrence  of  cases  of  disease  in  order  that  standard  pre¬ 
cautionary  measures  could  be  taken  and  of  holding  suspects  during  the  period 
of  incubation  was  as  evident  in  Mead’s  day  as  in  this. 

Vaccination  against  small-pox  has  been  available  as  a  public-health  measure 
since  1798  and  has  been  practiced  in  Baltimore  since  1800,  but,  as  elsewhere, 
in  a  fashion  quite  inadequate.  But  the  value  of  variola  inoculata  as  a  preventive 
measure  against  variola  vera  or  small-pox  was  announced  in  England  by  Lady 
Mary  Wortley  Montagu,  in  1716,  and  in  1744  the  western  world  was  informed 
through  Mead’s  publication  of  an  English  translation  of  Rhazes’s  classical 
work  on  small-pox  that  the  Chinese  and  other  eastern  peoples  had  for  centuries 
employed  successfully  variola  inoculata  as  a  substitution  disease  against 
small-pox.  Indeed,  the  great  virtue  of  Jenner’s  discovery  lay  in  the  fact  that 
vaccinia  is  a  milder  affection  than  variola  inoculata  and  that  its  use  avoids 
keeping  the  small-pox  virus  alive  in  a  community. 

Almost  from  time  immemorial,  pulmonary  tuberculosis,  like  leprosy,  has 
been  held  to  be  spread  by  intimate  personal  contact;  yet  the  latter,  during  many 
centuries,  has  been  combated  by  segregation  (and  apparently  with  great  success 
in  Europe),  while  restrictive  measures  against  the  former  have  come  into  vogue 
only  in  recent  years,  and  then  on  a  very  restricted  scale.  When  the  difference 
in  man’s  conduct  toward  these  two  affections  is  considered,  it  seems  likely  that 
his  actions  must  have  been  governed  more  by  vanity  and  horror  than  by  reason. 
It  is  doubtful  if  leprosy  was  ever,  within  historic  times,  endowed  with  a  force 
of  morbidity  and  mortality  of  the  same  high  degree  as  was  pulmonary  tuber¬ 
culosis.  The  disease  of  lesser  frequency  is  characterized,  however,  by  visible 
lesions  leading  to  hideous  deformities  and  superficial  decay  and  attended  by 
feelings  of  despair,  while  with  its  more  common  and  usually  more  rapidly 
fatal  sister  the  lesions  are  hidden,  hope  commonly  persists  to  the  end,  and  the 
victim  inspires  sympathy  rather  than  disgust.  It  is  interesting  to  speculate 
on  what  would  have  happened  had  the  ancients  applied  segregation  to  the 
pulmonary  tuberculous  with  the  same  determination  with  which  they  exercised 
it  on  the  leprous. 

It  would  appear  that  until  the  middle  of  the  nineteenth  century  western 
Europe  and  North  America  were  stirred  to  activities  of  disease  control  only  by 
deadly  epidemics,  mainly  those  of  diseases  marked  by  horrible  external  char¬ 
acters.  Small-pox,  disgusting  to  sight  and  smell  and  marked  by  facial  defor¬ 
mities  and  blemishes  in  the  recovered,  plague  with  its  discoloration  of  the  skin 


100  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

and  its  suppurating  buboes,  and  the  contagious  ophthalmia  of  the  East,  dis¬ 
figuring  man’s  best  feature  and  commonly  leaving  a  legacy  of  blindness,  all 
illustrate  this  point.  Typhus  fever,  influenza,  scarlet  fever,  measles,  diph¬ 
theria,  whooping-cough,  syphilis  and  gonorrhoea,  and  the  less  dangerous  mumps 
and  varicella — diseases  then  and  now  commonly  reckoned  as  contactively 
spread — excited  only  occasionally  administrative  reactions  of  a  protective 
nature.  Syphilis  has  excited  popular  dread  only  when  its  victims  showed  super¬ 
ficial  lesions  with  destruction  of  tissue  and  disgusting  appearances  and  odors. 
The  same  may  be  said  of  superficial  tuberculosis  or  scrofula.  Gonorrhoea  is  yet 
regarded  popularly  as  too  mild  a  disease  to  call  for  the  use  of  the  obvious 
measures  to  avoid  it. 

In  Baltimore  the  early  sanitary  measures  undertaken  against  diseases  sup¬ 
posedly  caused  by  effluvia  from  the  decaying  of  dead  organic  matter  were 
inspired  as  much  by  the  fear  of  the  dreaded  yellow  fever  as  by  fear  of  the  cus¬ 
tomary,  annual  visitation  of  malarial  diseases,  to  which  a  great  proportion  of 
the  deaths  were  attributed  every  year. 

Against  endemic  affections  of  steady  march  and  less  spectacular  lethal  capaci¬ 
ties,  man  commonly  exhibited  stolid  indifference,  fostered  by  familiarity, 
superstition,  and  a  feeling  of  helplessness. 

The  discovery  since  1898  that  malaria  and  yellow  fever  are  carried  by  mos¬ 
quitoes  acting  as  intermediary  hosts,  and  that  typhus  fever  is  spread  from  sick 
to  well  by  body-lice,  was  not  essential  for  a  considerable  control  over,  if  not 
for  the  eradication  of,  these  diseases,  and,  indeed,  they  all  had  shown  marked 
regression  and  had  practically  disappeared  in  many  countries  before  this  time. 
In  fact,  it  is  not  going  to  far  to  state  that  malaria  and  yellow  fever  had  been 
eliminated  or  in  great  degree  curbed  in  many  places,  including  Baltimore, 
long  before  it  was  demonstrated  that  they  are  caused  by  micro-parasites  and 
under  natural  conditions,  at  least,  transmitted  only  through  the  mediation  of 
certain  species  of  mosquitoes.  Measures  directed  against  standing  water,  such 
as  draining  and  filling  low  grounds,  making  cellars  dry,  sealing  cesspools, 
planting  trees,  and  the  like,  are,  of  course,  of  equal  value  in  preventing  mos¬ 
quito  breeding  and  the  formation  or  the  escape  into  the  air  of  effluvia  from 
decaying  organic  matter.  The  avoidance  of  low  grounds  and  of  exposure  to 
the  open  air  at  night,  precautions  taken  for  empirical  reasons,  are  efficacious 
for  escaping  malaria  and  yellow  fever,  when  prevalent,  whether  adopted  under 
the  influence  of  the  marsh  miasma  or  the  mosquito  theory.  The  mosquito  net 
and  the  window  screen  were  in  general  use  long  before  the  relation  of  these 
insects  to  the  spread  of  these  fevers  was  discovered.  Finally,  the  value  of 
routine  doses  of  cinchona  bark,  or  of  its  active  principle,  quinine,  in  warding 
off  malarial  infection  in  malarious  districts  has  long  been  recognized.  This 
practice  was  successfully  employed  in  the  eighteenth  century  in  armies,  in  the 
British  navy,  in  the  British  settlements  on  the  Guinea  coast,  and  elsewhere. 
During  the  nineteenth  century,  preventive  doses  of  cinchona  bark  or  of  quinine 
in  whisky  or  brandy  (as  first  used  in  the  Imperial  army  on  the  Danube  in 
1717-1718)  became  a  commonly  practiced  measure  of  personal  hygiene  in 
Baltimore.  According  to  Dr.  W.  T.  Councilman,  this  prophylactic  remedy  was 
furnished  by  the  Baltimore  health  department  as  late  as  1880  to  the  officials 
and  help  at  the  quarantine  station,  which  was  situated  in  a  severely  malarious 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


101 


district.  It  was  taken  twice  daily  by  the  whole  force,  and  hy  one  employee 
in  amounts  sufficient  to  cause  permanent  deafness.  Until  very  recent  years  it 
was  the  fixed  habit  of  physicians  in  Baltimore  to  pour  quinine  into  patients 
suffering  with  various  diseases  whenever  a  “  malarial  complication  ”  was 
suspected.  As  dysentery  was  believed  to  he  an  “  expression  of  malarial  intoxi¬ 
cation  ”  (and  doubtless  the  two  diseases  often  coexisted  in  the  same  individ¬ 
ual),  quinine,  or  “the  bark/’  was  commonly  administered  for  this  disease  as 
a  matter  of  routine.  It  is  a  curious  fact  that  until  very  recently  health  depart¬ 
ments  failed  to  advocate  the  use  of  prophylactic  doses  of  quinine  for  the  control 
of  malaria,  and  not  until  much  later  did  they  distribute  quinine  free  of  cost. 
The  latter  measure  of  health  protection  was  not  adopted  until  long  after  the 
free  distribution  of  diphtheria  and  tetanus  antitoxins  and  other  curative  and 
prophylactic  sera  and  of  vaccine  and  various  bacterial  vaccines.  In  Balti¬ 
more  the  records  show  that  far  more  deaths  were  credited  to  malaria  than 
to  small-pox,  and  for  many  years  malaria  certainly  killed  more  than  did 
diphtheria. 

For  illustrations  of  the  effectiveness  of  sanitary  measures  and  cinchoniza- 
tion  of  populations  upon  the  course  of  malaria,  long  before  the  discovery  of 
the  malarial  parasites  and  the  influence  of  the  mosquito  in  their  spread  from 
man  to  man,  it  is  only  necessary  to  follow  the  epidemiology  of  this  disease  in 
England,  in  western  Europe,  and  in  the  northern  States  of  America. 

Malarial  fevers,  in  severe  and  fatal  form  at  least,  had  disappeared  from 
large  sections  of  England,  France,  and  Italy,  and  even  the  Low  Countries, 
long  before  the  discovery  of  the  causal  agents  and  their  spread  by  intermediate 
hosts,  under  treatment,  both  curative  and  preventive,  by  “  the  bark  ”  and 
through  measures  directed  against  standing  water  and  putrefaction  of  vege¬ 
table  material  on  the  marsh-effluvia  theory.  The  non-contagious  character  of 
malaria  was  well  established  centuries  ago  and  of  yellow  fever  early  in  the 
nineteenth  century.  The  experiments  of  Ffirth  and  of  Potter  showed  as  conclu¬ 
sively  as  did  those  of  the  Reed  Commission  nearly  100  years  later  that  yellow 
fever  can  not  be  spread  by  fomites,  and  furthermore  proved  that  in  the  height 
of  the  disease  successful  transmission  from  one  human  being  to  another  by 
direct  inoculation  of  the  black  vomit  and  of  whole  blood  into  the  stomach  is 
not  practicable. 

Typhus  or  goal  fever  was  shown  in  Mead’s  time  to  be  successfully  combated 
by  measures  directed  toward  personal  cleanliness,  such  as  shaving,  hair-cutting, 
bathing  the  body,  and  the  destroying  or  disinfecting  by  heat  or  chemicals  of 
clothing,  bedding,  and  the  like.  This  fact  was  amply  verified  later  by  Pringle, 
Monro,  Lind,  John  Howard,  and  others.  The  relation  of  overcrowding,  famine, 
and  wars  to  the  spread  of  typhus  fever  was  as  well  or  even  better  appreciated 
then  than  at  present.  Indeed,  typhus  fever  in  epidemic  form  had  died  out  in 
western  civilization  long  years  before  the  relation  of  the  body-louse  to  the 
transmission  of  the  disease  was  discovered.  Thus,  by  the  middle  of  the  nine- 
tenth  century,  typhus  had,  without  any  special  sanitary  measures  directed 
against  it  by  public-health  authorities,  become  a  disease  of  comparative  rarity 
except  in  Ireland,  Poland,  Russia,  and  the  poorer  parts  of  Germany,  Italy,  and 
southeastern  Europe,  in  which  localities  the  mass  of  the  people  was  poverty- 
stricken  and  lived  continuously  in  those  conditions  of  filth  that  favor  vermi¬ 
nous  infestation. 


102 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


In  English,  and  even  in  Scotch  cities,  without  organized  health  departments, 
typhus  fever  became  relatively  uncommon  and  was  confined  to  the  very  poor  and 
to  Irish  immigrants,  by  whom  it  was  being  constantly  imported.  After  1840, 
the  epidemics  of  this  disease  in  Baltimore,  as  will  be  shown  later,  were  imported 
from  one  or  the  other  of  its  homes  in  Europe  and  spread  only  among  those 
uncleanly  through  poverty  and  ignorance. 

It  will  be  recalled  that  long  before  the  modern  revival  in  sanitation,  the 
great  advances  in  knowledge  of  micro-parasitology,  and  the  general  acceptance 
of  the  germ  theory  of  the  causation  of  the  communicable  diseases,  the  idea 
(with  which  from  their  practices  it  is  legitimate  to  infer  that  the  ancients 
were  familiar)  that  causation  of  the  acute  intestinal  diseases  is  intimately 
associated  with  pollution  of  drinking  water  with  human  excreta  had  been 
revived  or  rediscovered.  It  has  been  shown  in  a  previous  chapter  that  David 
Monro  recognized  this  association  in  1763.  Parkes  (38)  lias  pointed  out  that 
diarrhoeal  diseases  were  attributed  to  impure  drinking-water  at  Gottingen  in 
1760,  at  Saarlouis  by  Walz  in  1822,  at  Mayence  by  Muller  in  1843,  and  at 
Vienna  by  Richter  in  1848.  By  Austin  Flint  (39)  at  North  Boston,  N.  Y.,  in 
1843,  and  in  England  by  Carpenter  (38)  in  1852,  Rauth  (38)  in  1856,  and  very 
conclusively  by  Budd  in  1859,  the  important  relation  between  the  spread  of 
typhoid  fever  and  polluted  drinking-water  was  shown.  The  possibility  of  the 
transmission  of  cholera  by  drinking-water  was  pointed  out  by  Jameson  (38) 
in  India  in  1820,  and  by  Muller  (38)  in  Hanover  in  1848.  This  means  of 
transmission  of  cholera  was  clearly  established  by  the  work  of  Snow  (40)  in 
1849,  and  especially  by  the  experiences  in  connection  with  the  celebrated 
Broad  Street  pump  in  London  in  1854.  The  masterly  paper  of  Snow  in  1849 
on  the  pathology  and  mode  of  spread  of  cholera  appeared  some  years  after  the 
great  sanitary  reforms  in  London  and  certain  other  British  cities  in  regard  to 
purer  water-supplies  and  more  effective  methods  of  sewage  disposal  had  been 
undertaken  on  the  old  miasma  theory.  Snow  argued  that,  since  the  primary 
and  essential  lesions  of  cholera  are  in  the  intestines  and  the  materies  morbi 
must  be  present  and  capable  of  multiplying  in  the  exudation  from  the  mucous 
membrane  of  these  organs,  the  disease  must  be  disseminated  from  sick  to  well 
through  the  intestinal  discharges.  From  a  large  number  of  experiences  drawn 
from  London  and  elsewhere  he  arrived  at  two  important  generalizations ;  first, 
that  numerous  opportunities  existed  for  the  spread  of  cholera  in  households 
by  transferring  cholera  dejecta  to  the  mouths  of  attendants  and  others  from 
stools  and  soiled  bedding  directly  by  the  hands  or  indirectly  through  foods; 
and,  second,  that  drinking-waters  were  impregnated  with  the  unknown  causal 
agent  of  cholera  by  contamination  from  drains,  cesspools,  and  streams  polluted 
with  the  intestinal  discharges  of  cholera  patients.  He,  therefore,  advised  that 
attendants  upon  cholera  patients  should  wash  their  hands  before  eating,  that 
soiled  bed-linen  should  be  boiled,  and  that  fruit  hawked  about  the  streets  (for 
the  contamination  of  which  there  were  many  opportunities)  should  be  avoided. 
Against  infection  by  drinking-water  Snow  was  no  less  definite : 

“  And,  lastly,  whilst  cholera  remains  in  the  country,  people  should  avoid  using  water 
which  receives  the  contents  of  drains  or  sewers,  or  the  refuse  of  persons  navigating 
the  water.  Since  anything  touched  by  the  hands  may  enter  the  mouth,  it  would  be 
desirable  to  avoid  even  washing  with  such  water;  and,  at  all  events,  when  no  other 
water  can  be  obtained,  so  much  of  it  as  is  used  for  drinking  and  culinary  purposes 
should  be  filtered  and  well  boiled.” 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


103 


As  late  as  1873  Budd  (41)  felt  it  necessary  to  submit  data  to  prove  that 
“  typhoid  fever  is  a  contagious  fever  propagated  by  a  specific  poison/’  that  the 
intestinal  lesions  are  the  characteristic  feature  of  the  disease,  and  that  “  what 
is  cast  off  from  the  intestine  is  incomparably  more  virulent  than  anything  else.” 
While  strongly  imbued  with  the  idea  that  the  disease  could  be  spread  through 
the  air,  he  held  the  same  views  regarding  the  importance  of  the  stools,  bedding, 
and  polluted  water  in  the  spread  of  typhoid  that  Snow  had  enunciated  in  regard 
to  cholera.  Budd  laid  great  stress  upon  the  importance  of  the  disinfection  of 
stools  of  typhoid  patients,  and  he  even  considered  it  highly  probable  that  the 
disease  is  spread  by  means  of  milk  and  butter.  The  demonstrations  of  Snow 
and  Budd  of  the  important  relation  between  polluted  water  and  the  spread  of 
cholera  and  typhoid  exercised  without  doubt  a  considerable  influence  in 
accelerating  the  movements  already  on  foot  to  secure  purer  drinking-wrater  and 
safely  to  dispose  of  human  dejecta,  but  their  discovery  of  the  role  played  by 
direct  infection  by  the  hands  and  of  indirect  infection  through  foods  con¬ 
taminated  with  the  stools  of  those  ill  with  these  diseases  did  not  bear  fruit  for 
many  years.  It  must  be  recalled  that  the  importance  of  infected  milk  in  the 
transmission  of  typhoid,  scarlet  fever,  and  diphtheria  was  proven  in  the  ninth 
decade  of  the  last  century  as  the  result  of  epidemiological  studies  made  without 
the  assistance  of  the  methods  of  micro-parasitology.  Snow  and  Budd  made 
the  additional  very  important  discovery,  namely,  that  unsanitary  conditions, 
such  as  overflowing  and  unprotected  privies  and  cesspools  and  water  polluted 
with  night-soil  and  other  putrescible  matters,  do  not  of  themselves  give  rise  to 
cholera  and  typhoid  fever,  but  act  as  vehicles  of  transmission  of  their  causal 
agents  after  these  diseases  have  been  introduced  into  communities.  So  deeply 
rooted  in  men’s  minds  was  the  miasma  theory  in  relation  to  the  causation  of 
the  acute  intestinal  disease  that  it  continued  to  flourish  under  the  guise  of  the 
sewer-gas  theory,  overthrown  in  the  later  years  of  the  nineteenth  century  by 
exact  studies  in  micro-biology. 

At  the  beginning  of  the  nineteenth  century  some  cities  in  Europe  and  in 
America  returned  to  the  ancient  practices  of  obtaining  general  water-supplies 
from  a  distance,  often  from  unpolluted  water-sheds,  and  of  constructing 
better  and  more  adequate  sewers.  In  these  undertakings  the  inhabitants 
were  influenced  in  part  by  the  wisdom  of  the  ancients  and  in  part  by  the 
miasma  theory  of  the  origin  of  certain  diseases.  London  and  certain  German 
cities  which  were  not  convenient  to  unpolluted  lakes  and  streams  had  adopted 
by  1850  filtration  systems  of  one  kind  or  another.  In  many  cases  filtration 
resulted  in  clarification  without  purification.  From  this  time  on  and  until 
the  development  of  water  bacteriology,  a  reasonable  degree  of  control  of  puri¬ 
fication  was  maintained  at  some  places  by  the  use  of  the  methods  of  chemical 
analysis. 

The  establishment  of  thoroughly  efficient  systems  of  water  and  sewage  puri¬ 
fication  by  the  filtration  method  would  be  difficult,  though  not  impossible 
without  the  discoveries  of  micro-parasitology.  This  does  not,  however,  vitiate 
the  argument,  for  in  the  case  of  both  water  and  sewage  this  method  is  only  one 
of  several.  Many  cities,  especially  those  situated  on  or  near  sea-coasts  or  on 
large  rivers,  obtain  pure  water  and  dispose  of  sewage  satisfactorily  without 
employing  the  filtration  method  for  either.  A  knowledge  of  micro-parasitology 


104  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

was  certainly  not  necessary  to  guide  Liverpool,  Glasgow,  and  other  cities  to 
obtain  pure  water  from  distant  lakes,  Munich  from  nearby  mountains,  New 
York  and  Boston  and  great  numbers  of  other  cities  from  protected  water-sheds, 
Chicago  to  divert  sewage  outfalls  from  water  intakes,  and  to  disclose  the 
influence  of  large  storage  reservoirs  upon  water  purification.  The  same  may 
be  said  of  water  purification  by  chlorine  and  other  chemicals.  Sewage  puri¬ 
fication  by  filtration  is  and  probably  will  continue  to  be  the  exception  and  not 
the  rule.  After  all,  it  is  by  the  incidence  and  mortality  of  the  intestinal  dis¬ 
eases,  rather  than  by  the  tests  and  standards  of  micro-parasitology,  that  these 
questions  are  judged.  It  is  not  sought  here  to  disparage  these  methods,  the 
great  importance  of  which  will  receive  proper  consideration  in  future  chapters, 
but  to  point  out  that  without  them  man  possessed  methods  to  obtain  pure 
water-supplies  and  to  construct  safe  methods  of  sewage  disposal.  Much  more 
important  agents  to  these  ends  than  micro-parasitology  were  the  invention  and 
perfection  of  the  steam-engine  and  the  electric  dynamo,  without  which  many 
modem  cities  could  hardly  have  been  developed  in  their  present  form. 

That  the  dangers  of  polluted  water  were  realized  in  early  Baltimore  is 
attested  by  the  facts  that  the  commissioners  appointed  in  1803  to  report  on  a 
general  water  supply  were  instructed  to  select  a  stream  “  for  a  copious  and 
permanent  supply  of  wholesome  water,”  and  as  early  as  1817  ordinances  were 
passed  designed  to  protect  springs  and  wells  from  nearby  privies  and  cesspools. 
Except  where  religious  doctrines  and  racial  prejudices  have  acted  as  con¬ 
trolling  factors,  as  among  the  Jews,  peoples  of  western  civilization  did  not, 
until  recent  years,  beyond  avoiding  food  evidently  tainted  by  putrefaction, 
concern  themselves  with  the  relation  of  foods  to  the  spread  of  diseases.  It  is 
probable  that  the  revival  of  the  old  germ  theory  of  disease,  or  rather  the  demon¬ 
stration  that  certain  dangerous  affections  transmissible  from  food  animals  to 
man  are  caused  by  living  parasites,  is  to  a  considerable  degree  responsible  for 
the  inauguration  of  the  modern  system  of  food  inspection  designed  to  protect 
man  against  anthrax,  glanders,  tuberculosis,  actinomycosis,  and  trichinosis.  As 
a  matter  of  fact,  however,  the  identity  of  most  of  these  diseases  in  man  and  in 
the  food  animals  was  established  at  least  as  much  by  pathological  anatomy  as 
by  micro-parasitology,  and  the  relation  of  milk  to  the  spread  of  such  diseases 
as  typhoid  fever,  scarlet  fever,  and  diphtheria  was  established  before  the 
influence  of  micro-parasitology  was  brought  to  bear  upon  public-health  admin¬ 
istration. 

It  is  clear,  then,  that,  long  before  the  days  of  modern  micro-parasitology, 
there  existed  abundant  knowledge  and  experience  upon  which  to  base  large 
schemes  of  sanitation  and  of  personal  restriction  for  the  control  of  morbidity 
and  mortality  of  certain  diseases.  Some  other  reasons  than  ignorance  and  lack 
of  ideas  and  methods  must  be  found  to  explain  dilatoriness  of  action.  Some 
of  these  reasons  are  not  difficult  to  find. 

Europe,  after  the  fall  of  Rome,  through  the  Bark  Ages,  the  Middle  Ages, 
and  well  into  the  present  era,  was  essentially  barbarous.  Wars,  famine,  poverty, 
and  pestilence  were  the  natural  order.  The  great  mass  of  the  people  were 
little  better  than  slaves,  their  bodies  to  secular  and  their  minds  to  ecclesiastical 
princes — two  masters  often  joined  in  the  same  person.  Hence,  man’s  intellect 
was  dwarfed  by  superstition,  religious  intolerance,  and  ignorance.  Since  the 
chief  outlet  for  talent  was  centered  in  the  church,  secular  callings  for  the  few 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


105 


who  were  able  to  rise  and  to  make  a  choice  were  at  a  discount.  In  cities, 
streets  were  narrow,  winding,  and  filthy,  and  the  dwellings  were  not  only 
ill-adapted  for  such  use,  but  were  often  insufficient  in  number.  As  late  as 
1830,  18,000  people  in  Hamburg  lived  in  cellars,  or  tunnels,  to  which  daylight 
never  penetrated,  and  the  walls  and  floors  of  which  were  wet  and  befouled  with 
garbage  and  human  excreta.  To  go  back  no  further  than  to  the  fifteenth  cen¬ 
tury,  the  Hundred  Years  War  had  desolated  large  areas  of  Europe.  As  a 
result  of  the  Thirty  Years  War,  the  population  of  Germany  is  said  to  have 
fallen  from  20,000,000  to  4,000,000.  The  wars  of  Frederick  the  Great  left 
Prussia  and  Silesia  and  Saxony  impoverished  and  the  populations  greatly 
reduced.  The  condition  of  much  of  France  for  over  100  years  before  the 
Revolution  of  1789  was  one  of  impoverishment.  Italy  and  the  Low  Countries 
had  been  repeatedly  ravished.  Spain,  the  home  of  intolerance  and  of  popular 
ignorance  and  poverty,  was  in  decline.  In  Russia  and  southeastern  Europe, 
tyranny,  poverty,  and  ignorance  were  even  more  marked.  Such  was  the 
continent  that  faced  the  wars  of  the  French  Revolution  and  of  the  Napoleonic 
era.  In  no  country  of  Europe,  not  even  in  England,  had  the  sanitary  improve¬ 
ments  and  measures  of  the  Romans  survived.  The  minds  that  planned  and  the 
hands  that  built  the  great  cathedrals  at  Paris,  at  Rheims,  at  Cologne,  and  else¬ 
where  on  the  continent,  and  the  Abbey  of  Westminster  and  the  great  English 
cathedrals,  did  not  reproduce  or  even  keep  in  repair  the  sanitary  sewers  and  the 
pure-water  systems  of  the  Roman  civilization.  Even  with  the  wealth  of  the 
church  and  the  cheapness  of  labor,  the  time  occupied  in  the  erection  of  the  cathe¬ 
drals  was  measured  by  centuries  rather  than  by  years.  With  a  few  striking  excep¬ 
tions,  the  relatively  small  wealth  existant  was  concentrated  in  the  hands  of  the 
few — the  nobles  and  the  ruling  princes — and  in  the  church,  and  the  great  mass 
of  the  people  were  in  poverty.  The  middle  class,  represented  largely  by  organ¬ 
ized  artisans,  merchants,  and  bankers,  was  relatively  small  and  the  markets 
were  restricted. 

The  revival  and  growth  of  sanitary  reforms  and  systems  of  public  health 
administration  were  impossible  until  the  human  intellect  was  unshackled  from 
the  chains  of  antiquity  and  religious  superstition,  and  the  dense  ignorance 
and  poverty  imposed  by  secular  and  ecclesiastical  tyranny  were  in  some  con¬ 
siderable  degree  overcome.  These  chains  were  first  cast  off  in  Italy,  France, 
and  England  as  the  result  of  the  growth  and  development  of  the  spirit  of  scep¬ 
ticism  and  of  inquiry  in  the  fifteenth,  sixteenth,  seventeenth,  and  eighteenth 
centuries  which  brought  about  religious  and  political  freedom,  enormous 
expansion  of  knowledge,  and  the  production  and  accumulation  of  wealth. 

The  wonderful  outburst  in  certain  Italian  cities  of  intellectual  freedom, 
associated  also  with  the  gaining  of  great  wealth  from  art,  manufacture,  banking, 
shipping,  and  other  great  commercial  undertakings,  was  followed  by  a  revival 
of  interest  in  public  health  and  the  reestablishment  of  health  departments  and 
the  development  of  civic  improvements  of  a  sanitary  nature.  Under  constant 
threat  of  plague  from  the  Turkish  dominions,  the  maritime  cities  of  Italy 
developed  the  modern  quarantine  system.  But,  with  the  loss  of  trade  and  the 
consequent  decline  of  wealth  and  intellectual  culture,  and  of  their  diffusion  in 
the  population  following  the  development  of  the  ports  of  northern  Europe,  and 
the  loss  by  conquest  of  the  relatively  incomplete  degree  of  popular  political  free¬ 
dom,  public  health  administration  and  general  sanitary  improvements  not 


106  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

only  ceased  to  advance,  but  lapsed  into  conditions  as  primitive  as  those  of  Spain, 
France,  and  central  and  northern  Europe,  and  lay  dormant  until  the  general 
sanitary  revival  of  the  last  quarter  of  the  nineteenth  century. 

Just  as  in  England  after  a  long  struggle,  the  human  intellect  first  gained  a 
goodly  measure  of  freedom,  so  England  was  the  first  country  to  produce  in 
numbers  distinguished  investigators  in  all  branches  of  knowledge  and  to 
attain  popular  government  and  considerable  wealth,  with  the  general  diffusion 
of  both  knowledge  and  wealth  among  the  people.  There  is  ample  reason,  there¬ 
fore,  why  that  country  should  have  early  taken  the  first  place  in  Europe  in 
public-health  investigation  and  administration.  It  was  not  until  the  nine¬ 
teenth  century,  however,  that,  even  there,  conditions  were  favorable  for  any 
considerable  progress.  Nor  is  it  surprising  that  people  of  the  same  blood, 
with  more  personal  freedom  and  a  wider  diffusion  of  knowledge  among  the 
general  population,  though  with  less  wealth  and  a  smaller  productivity  in 
fields  of  scientific  inquiry,  should,  in  the  early  history  of  their  municipalities 
(as  in  Baltimore),  while  following  very  closely  the  traditions  and  methods  of 
the  mother  country,  have  anticipated  the  English  in  municipal  health  legisla¬ 
tion  and  in  the  establishment  of  boards  of  health  with  medical  officers.  It  is 
not  strange  that,  so  long  as  few  striking  contributions  were  made  to  general 
and  to  medical  knowledge  and  until  wealth  was  accumulated  and  became  more 
generally  diffused,  American  municipal  public-health  administration  should 
have,  in  many  respects,  lagged  behind  that  of  England.  A  notable  point  of 
difference  was  dependent  upon  the  fact  that  the  early  advances  made  in 
England  were  in  large  degree  due  to  the  researches  and  methods  inaugurated 
and  supported  by  the  General  Government,  while  in  America  the  influence  of 
the  central  and  State  Governments  was,  until  recent  years,  practically  nihil. 
The  backwardness  of  public-health  administration  and  general  sanitation  in 
French  municipalities,  until  comparatively  recently,  was  doubtless  due  in 
great  part  to  the  struggles  to  obtain  political  freedom  and  to  obtain  wealth. 
Napoleon  I,  however  despotic  in  some  respects,  in  the  main  adhered  to  the 
basic  principles  of  the  saner  Bevolutionists  and  preserved  to  the  French  people 
the  freedom  they  had  gained.  He  not  only  fostered  science  and  education,  but 
besides  other  great  improvements,  drained  large  areas  of  France  and  in  Paris 
constructed  a  new  water-supply  system  and  numerous  sewers.  German  munici¬ 
palities  were  notoriously  lacking  in  these  respects  until  the  increase  in  pros¬ 
perity  and  in  popular  education  and  the  acquirement  and  exercise  of  a  greater 
degree  of  local  self-government  some  years  after  the  Franco-Prussian  War  of 
1870.  Even  in  that  country  sanitary  progress  began  in  the  free  cities  of 
Hamburg  and  Frankfort. 

Under  autocratic  governments,  the  ruling  classes  are  indifferent  to  distress, 
disease,  and  death  among  the  poorer  and  more  ignorant  classes,  and  these  people 
are  comparatively  helpless,  partly  on  account  of  superstition  and  partly  on 
account  of  their  ignorance  concerning  measures  that  would  improve  their 
condition  and  their  lack  of  power  to  extort  them.  Their  ignorance  has  no 
doubt  been  influenced  in  some  degree  by  the  very  diseases  under  which  they 
labored.  Autocratic  governments  do  not  inaugurate  measures  for  the  pro¬ 
tection  of  the  general  population  against  disease  until  a  stage  of  enlightened 
self-interest  is  attained,  or  until  the  demands  for  reforms  become  so  loud  and 
threatening  that  some  concession  is  made.  When  these  conditions  obtain, 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


107 


popular  government  is  in  sight.  Great  and  rapid  advances  in  public-health 
administration  and  practice  have  come  in  modern  times  from  peoples  with 
wealth  and  with  popular  governments.  Under  autocratic  governments,  knowl¬ 
edge  and  wealth  and  a  free  spirit  of  inquiry  have  rarely,  if  ever,  been  diffused 
among  the  general  population. 

In  free  governments,  as  in  American  cities,  with  all  classes,  and  average 
citizens  in  particular,  jealous  of  private  rights  of  both  property  and  person, 
citizens  are  loath  to  pass  laws  of  a  restrictive  nature  and  are  intolerant  of 
restrictive  measures  imposed  upon  them  by  elective  or  appointive  officials. 
Indeed,  they  reserve  the  right  to  have  all  laws  and  regulations  submitted 
through  their  courts  to  tests  not  only  of  constitutionality,  but  of  reasonableness. 
It  is  not  until  the  average  citizen  has  acquired  a  degree  of  information  through 
which  he  becomes  convinced  that  such  measures  are  not  only  reasonable,  but 
that  they  will  tend  to  act  to  the  advantage  rather  than  to  the  disadvantage  of 
himself  and  his  dependents,  that  he  will  consent  to  impose  the  restrictions 
involved.  Even  those  measures,  the  wisdom  of  which  he  is  convinced,  are  often 
postponed,  or,  if  undertaken,  are,  on  account  of  the  cost,  prosecuted  in  a  half¬ 
way  manner.  After  the  citizens  have  consented  to  a  course,  their  instruments, 
to  whom  are  committed  the  framing  of  necessary  laws  and  regulations  and 
their  administration,  and  the  planning  and  construction  of  necessary  works 
and  buildings,  may,  and  only  too  often  do,  lack  in  the  knowledge,  judgment, 
and  efficiency  necessary  for  success.  There  is  a  wide  gap  between  recorded 
knowledge,  both  general  and  particular,  in  connection  with  any  subject  and 
the  proportion  of  knowledge  on  that  subject  possessed  by  those  to  whom  fall 
the  opportunity  and  responsibility  to  apply  it  to  popular  use. 

It  is  evident,  therefore,  that  to  attain  a  high  degree  of  efficiency  in  the  con¬ 
trol  of  disease,  a  people  must  have  obtained  a  considerable  amount  of  knowl¬ 
edge,  freedom,  and  wealth  and  to  be  able  to  obtain  health  officials  with  com¬ 
prehensive  and  accurate  information  concerning  both  the  natural  history  of 
diseases  and  the  fundamental  and  applied  sciences.  These  several  conditions, 
necessarily  precedent  to  successful  efforts  to  control  the  incidence  of  disease, 
have  never  fallen  together  in  Baltimore  (nor  in  any  other  municipality  for 
that  matter),  as  will  be  abundantly  shown  in  succeeding  chapters.  It  will  suffice 
to  point  out  here  that  the  failures  are  to  be  laid  to  both  public  and  officials. 
For  over  100  years  the  needs  in  connection  with  general  measures  outstripped 
in  growth  both  the  intelligence  and  the  wealth  of  the  population,  and,  until 
the  present  time,  the  general  officials  often,  and  the  chief  health  officials  nearly 
always,  were  so  fettered  by  ignorance  and  so  swathed  in  the  bands  of  tradition 
that  at  critical  times  the  former  were  incapable  of  demanding  and  the  latter 
were  incapable  of  creating  a  fully  rounded  health  department. 

The  peoples  whom  the  end  of  the  eighteenth  and  the  first  half  of  the  nine¬ 
teenth  centuries  found  with  liberal  institutions,  after  heavy  struggles,  were 
busy  consolidating  and  extending  their  gains.  The  mere  possession  of  methods 
was  not  sufficient  in  itself  among  peoples  not  ready  to  use  them  routinely  and 
logically.  It  is  a  striking  fact  that  man,  although  he  had  formulated  long 
years  before  the  beginning  of  the  nineteenth  century  practically  the  same 
methods  of  control  that  he  now  uses  against  most,  at  least,  of  the  typically  con- 
tactive  diseases,  has  been  much  more  willing  to  attack  the  nuisance  or  effluvial 

8 


108  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


diseases.  His  actions  in  this  respect  were  probably  determined  by  several 
considerations.  In  the  first  place,  the  necessary  measures  were  directed  to 
things  rather  than  to  persons,  and  therefore  violated  to  a  lesser  degree  his 
inherent  sense  of  personal  liberty  and  interfered  less  with  his  capacity  to  earn 
a  living.  Secondly,  after  he  had  acquired  knowledge  and  wealth,  and  both 
these  attributes  had  become  diffused  with  a  degree  of  equality  hitherto  un¬ 
known,  he  developed  a  sense  of  decency,  a  feeling  of  self-respect  and  personal 
pride,  a  sense  of  the  fitness  of  things,  which  resulted  in  a  marked  change  in 
manners  and  customs,  both  public  and  private.  As  a  result,  conditions  of  living 
and  surroundings  that  had  previously  offended  the  few  were  by  the  end  of  the 
eighteenth  century  distasteful  to  the  many.  It  is  not  at  all  strange  that  the 
English,  to  whom  wealth  with  the  power  to  use  it  came  first,  should  have  been 
the  first  as  a  nation  to  emerge  from  the  relative  barbarity  of  the  sixteenth  and 
seventeenth  centuries  and  to  acquire  and  then  to  gratify  a  taste  for  decency 
in  municipal,  household,  and  personal  surroundings,  nor  is  it  remarkable  that 
this  attitude  should  be  reflected  to  their  descendants  in  North  America.  In 
the  third  place,  efforts  to  influence  the  environment  promised  a  richer  return 
than  those  expended  against  persons,  for  they  had  some  striking  results  to 
their  credit,  while  on  the  other  hand  experience  had  shown  that,  so  far  as 
attempted,  measures  to  restrict  diseases  spread  especially  by  personal  contact 
had  very  generally  failed  signally. 

In  the  light  of  these  reflections  it  will  not  seem  remarkable  that  in  Baltimore, 
as  will  appear  in  later  chapters,  during  most  of  the  nineteenth  century,  the 
efforts  of  the  health  and  other  civic  authorities  were  directed  within  the  city 
chiefly  against  diseases  classed  as  miasmatic,  efiluvial,  or  infectious,  and  that, 
with  the  exception  of  small-pox,  the  contactive  diseases  received  but  scant 
attention.  The  sequel  has  shown  that,  imperfect  and  inadequate  as  were  their 
applications  of  the  measures  used,  and  far  short  as  they  fell  of  what  they  might 
have  accomplished,  the  early  Baltimoreans  took  the  better  of  the  two  bets. 

The  primary  and  fundamental  steps  in  the  logical  application  of  Mead’s 
recommendations  in  controlling  a  given  disease  are  the  early  recognition  and 
the  reporting  of  all  cases  to  the  authorities,  and  yet  it  was  not  until  1889  in 
London  and  1882  in  Baltimore  that  laws  were  passed  requiring  routinely  the 
prompt  reporting  of  certain  acute  febrile  diseases.  Though  in  England  and 
Scotland  notification  of  febrile  diseases  was  enforced  in  a  few  urban  districts 
as  early  as  1876,  it  was  not  widely  adopted  before  1882.  Prior  to  the  act 
of  1889,  making  notification  compulsory  for  all  London  but  optional  else¬ 
where,  17  of  the  28  greater  towns  of  England  had  adopted  it  and  11  had  not. 
The  latter  act  specified  as  reportable  diseases,  cholera,  small-pox,  scarlatina, 
typhus,  enteric,  relapsing,  and  puerperal  fevers,  diphtheria,  and  erysipelas. 
In  Baltimore,  the  very  incomplete  list  embraced  only  small-pox,  scarlet  fever, 
cholera,  yellow  fever,  malignant  diphtheria,  and  varioloid,  all  but  one  of  which 
were  then  locally  regarded  as  typically  contactive  in  mode  of  spread,  the 
essential  cause  of  none  having  been  discovered  up  to  that  time,  and  that  of 
only  two  (cholera  in  1883  and  diphtheria  in  1884)  having  been  conclusively 
identified  up  to  the  present.  The  other  diseases  since  added  to  the  list  by 
city  ordinance  are  membranous  croup,  measles,  mumps,  and  whooping-cough 
in  1890,  and  typhoid  fever  in  1895. 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


109 


It  is  clear  that  the  earliest  of  these  laws  were  passed  before  the  discoveries 
of  modern  micro-parasitology  had  begun  to  exert  any  direct  and  controlling 
influence  upon  public-health  administration.  In  Baltimore  the  law  of  1882  was 
passed  during  the  height  of  one  of  the  most  severe  epidemics  of  small-pox  the 
city  had  experienced.  From  the  evidence  at  hand  it  is  clear  that  this  was 
inspired  by  an  attempt  to  make  small-pox  a  reportable  disease  permanently, 
and  advantage  was  taken  of  the  opportunity  to  include  the  other  diseases,  some 
of  which  had  been  widely  epidemic  and  very  fatal  a  few  years  before. 

Besides  those  considerations  of  a  general  nature,  there  were  others  of  a 
more  specific  character  that  obviously  impeded  the  development  of  municipal 
sanitation  and  public-health  administration  in  the  latter  part  of  the  eighteenth 
and  throughout  the  nineteenth  centuries.  The  most  important  of  these  was 
the  very  rapid  and  unprecedented  growth  of  urban  populations,  due  not  to 
excess  of  births  over  deaths,  but  to  immigration,  either,  as  was  particularly 
true  of  Great  Britain,  a  migration  from  country  and  village  to  cities,  or,  as  in 
North  America,  an  immigration  from  abroad  as  well  as  from  the  above- 
mentioned  sources.  These  new  elements  were  disturbing  factors  in  many  w7ays. 
Influenced  by  a  lively  sense  of  self-interest  and  lacking,  at  least  in  the  be¬ 
ginning,  a  personal  sense  of  civic  loyalty  and  responsibility  engendered  by 
continuous  residence  and  by  generations  of  family  associations  and  traditions, 
their  presence  and  activities  upset  the  homogeneity  of  the  population  in  cus¬ 
toms  of  social  and  business  life,  in  kinds  and  directions  of  trade  and  manu¬ 
facture,  in  education,  in  politics,  and  often  in  religion.  Especially  disturbing 
in  these  ways  were,  of  necessity,  emigrants  from  foreign  countries,  on  account 
of  the  wide  divergences  of  customs  and  prejudices,  and  above  all  on  account 
of  differences  in  speech.  A  large  proportion  of  all  immigrants  to  cities,  whether 
from  the  same  or  foreign  countries,  were  deficient  in  education  and  training 
and  were  poor  in  purse.  Some  at  once,  and  many  more  with  even  slight  adversi¬ 
ties  in  business  and  trade,  became  burdens  upon  the  cities.  Their  mere  pres¬ 
ence  diverted  work  from  old  to  new  channels,  and  particularly  in  times  of 
business  boom,  stimulated  building,  increased  the  cost  of  living,  and  in  other 
ways  upset  the  balance  of  life.  They  caused  overcrowding  in  dwellings,  added 
to  the  cost  of  the  removal  of  waste,  and  their  presence  resulted  in  the  con¬ 
struction  of  dwellings  at  a  rate  that  far  outstripped  the  growth  of  paving, 
sewers,  and  water  supplies.  Thus,  there  have  so  often  resulted  cities  more 
or  less  solidly  built  up  in  the  central  area,  with  durable  and  well-constructed 
pavements,  surface  water  and  sanitary  sewers,  and  a  generous  water-supply, 
bordered  by  a  second  area,  with  poorly  paved  or  unpaved  streets,  with  sewers 
and  water-pipes  but  incompletely  extended,  and  with  conditions  of  general  sani¬ 
tation  varying  in  its  different  parts  from  a  semi-urban  to  a  village  state. 
Beyond  this  there  is  a  larger  or  smaller  zone,  with  scattered  villages  or  in  a 
partly  cultivated  rural  state,  where  the  general  sanitation  is  of  the  crudest  type. 
Parts  or  all  of  this  zone  are  finally  annexed.  It  not  infrequently  happens, 
therefore,  that  in  a  North  American  city  under  the  influence  of  rapid  growth  in 
population,  more  than  half  the  territory  and  a  third  or  more  of  the  population 
are  without  the  area  having  complete  sanitary  arrangements  in  regard  to 
paving,  sewerage,  water,  and  garbage  removal.  Even  when  the  money  can  be 
raised  to  furnish  sanitary  necessities,  the  work  occupies  years,  and  before  it  is 


110  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

completed  another  annexation  takes  place.  It  is  only  within  a  comparatively 
short  time  that  parts  of  the  second  and  third  zones  have  been  paved,  sewered, 
and  watered  by  the  owners  as  development  takes  place.  Migrants,  particularly 
from  other  countries  or  distant  parts  of  the  same  country,  have  often  brought 
in  and  kept  alive  diseases  that  were  dying  out,  or  have  imported  a  disease  in 
more  virulent  type.  Well-known  examples  are  the  importation  of  typhus  into 
Scotch  and  English  cities  by  Irish  immigrants,  and  the  importation  of  typhus, 
small-pox,  measles,  scarlatina,  and  other  diseases  into  Baltimore  by  Irish  and 
German  immigrants. 

Thus  it  is  that,  with  few  exceptions,  very  rapid  growth  in  population  and 
territory  must  react  unfavorably  upon  both  general  sanitation  and  personal 
hygiene  in  a  city.  In  Baltimore  the  action  of  all  these  factors  has  been  particu¬ 
larly  striking. 

The  great  influence  of  the  application  of  statistical  methods  to  the  study 
of  the  natural  history  of  disease  and  the  problems  of  public-health  adminis¬ 
tration  has  also  been  either  overlooked  or  not  duly  appreciated.  Used  first  in 
these  connections  in  the  construction  of  life  tables  as  a  basis  of  insurance,  these 
methods  were  then  applied  by  publicists  and  statesmen  in  determining  the 
laws  which  govern  the  growth  of  population  and  wealth;  by  pathological  anato¬ 
mists  in  the  study  of  the  comparative  frequency  of  diseases  and  of  particular 
lesions;  by  clinicians,  especially  the  French,  in  the  determination  of  case 
fatality  rates  in  different  diseases,  particularly  where  certain  methods  or  plans 
of  treatment  were  concerned;  and  later  by  medical  men,  general  statisticians, 
and  public-health  administrators  in  the  comparison  of  salubrity  of  climate  and 
general  environment  upon,  first,  general  morbidity  and  mortality,  and,  second, 
particular  diseases.  Shortly  after  the  middle  of  the  nineteenth  century,  under 
the  influence  of  William  Farr  and  his  pupils  in  England,  and  of  Lemuel 
Shattuck  of  Boston  and  of  Joynes  and  Frick  of  Baltimore  in  the  United  States, 
statistical  methods  had  become  a  determining  force  in  the  study  of  the  natural 
history  of  individual  diseases  and  in  the  whole  field  of  public-health  inquiry 
and  administration.  The  appreciation  of  statistical  methods  was  not  only 
responsible  for  discoveries  of  fundamental  importance  in  these  fields,  but  for 
the  important  means  of  diffusion  among  people  of  the  knowledge  acquired. 

Thus  it  was,  largely  at  least,  a  coincidence  that  the  discoveries  of  modern 
micro-parasitology  and  the  additional  practical  methods  of  disease  control 
derived  from  them  fell  at  a  time  when  a  large  and  the  most  intelligent  part 
of  mankind  was  ready  to  consider  and  to  apply  them.  With  certain  notable 
exceptions  these  discoveries  were  not  made  by  public-health  officials,  who  have 
on  the  whole,  but  very  clumsily,  slowly,  and  reluctantly,  applied  them.  How¬ 
ever,  instances  are  not  lacking,  in  the  history  of  Baltimore  in  particular,  of 
examples  of  health  officials  pleading  in  vain  for  means  and  power  to  under¬ 
take  measures  certain  to  exert  a  favorable  influence  on  the  public  health. 

The  coincidence  of  the  recognition  on  the  part  of  the  general  public  of  the 
importance  of  public-health  measures  of  a  wider  scope,  and  the  availability  of 
funds  to  carry  them  out,  with  the  great  discoveries  in  micro-parasitology, 
medicine,  surgery,  and  above  all  in  pathological  anatomy,  during  the  last  third 
of  the  nineteenth  century,  was  responsible  for  the  generally  prevalent  idea 
that  all  the  knowledge  and  power  of  man  over  the  control  of  diseases  are 
dependent  upon  them  and  certain  improvements  and  refinements  of  methods 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


111 


arising  out  of  them.  Curiously  enough,  at  the  same  time,  some  of  the  labors 
of  previous  years  began  to  bear  fruit,  and,  as  will  be  shown  later,  certain  wide¬ 
spread  and  conspicuous  diseases  (measles,  scarlatina,  typhus  fever,  and  small¬ 
pox)  happened  to  run  into  periods  of  decline,  wliich,  for  some  of  them  at 
least,  is  a  phase  of  their  natural  history,  a  fact  well  established  since  the 
days  of  Sydenham. 

Among  the  many  important  influences  ascribed  to  modern  medical  and 
zoological  knowledge  has  been  its  effect  upon  the  distribution  of  the  febrile 
diseases  among  the  old  classifications,  for  due  to  it  the  number  of  affections 
classed  under  the  nuisance  diseases  has  increased  at  the  expense  of  the  list  of 
those  classed  as  spread  by  immediate  contact.  This  has  largely  been  brought 
about  by  the  discovery  that  the  causal  agents  of  certain  affections,  such  as 
typhus  and  relapsing  fevers,  sleeping  sickness,  and  the  plague  are  spread  by 
insects  acting  either  as  intermediate  hosts  or  as  mechanical  carriers,  the 
presence  of  which  beings  in  man’s  environment  is  governed  by  conditions 
associated  with  nuisances  due  to  lack  of  cleanliness.  Another  advance  due  to 
this  knowledge  was  the  determination  that,  as  a  rule,  under  natural  conditions 
the  causal  agents  of  the  nuisance  diseases  enter  the  system  through  the  skin  or 
by  the  mucosa  of  the  gastro-intestinal  tract,  instead  of  by  the  lungs  only,  as 
was  supposed,  and  by  the  evidence  furnished  in  favor  of  the  view  that  the 
typical  contagious  diseases  of  a  general  systemic  type,  the  eruptive  diseases 
particularly,  such  as  small-pox  and  scarlet  fever,  as  a  class  invade  the  body 
by  the  respiratory  tract,  instead  of  through  the  skin,  as  was  often  formerly  held. 

To  be  classed  among  the  greatest  contributions  made  by  pathological  anatomy 
and  by  micro-parasitology  to  the  knowledge  of  the  natural  history  of  the 
febrile  diseases  applicable  to  public-health  administration  are  the  deter¬ 
mination  of  the  portals  of  entry  and  exit  of  their  causal  agents  to  and  from 
the  body  and  their  modes  and  channels  of  travel  within  the  body ;  the  charac¬ 
ters  and  varieties  of  lesions  produced,  particularly  those  determining  a  fatal 
issue;  the  forces  and  factors  concerned  in  recovery  and  particularly  in  immu¬ 
nity  ;  the  identity  of  various  diseases  common  to  both  man  and  lower  animals ; 
the  separation  on  an  etiological  basis  of  the  different  affections  characterized 
by  the  same  or  similar  clinical  symptoms  or  anatomical  changes;  and,  finally, 
a  series  of  methods  for  both  diagnosis  and  preventive  inoculation  based  upon 
pathological  anatomy,  direct  microscopy,  cultivation,  animal  experiment,  and 
immunity  reactions. 

The  application  of  the  methods  of  chemistry,  bacteriology,  and  zoology  to 
sanitary  engineering,  and  especially  to  standards  of  purity  of  water  and  of 
milk  and  other  foods,  are  of  the  greatest  importance. 

This  knowledge  in  these  various  fields  but  slowly  penetrated  the  minds  of 
public-health  administrators,  and  these  methods  came  into  use  in  health  depart¬ 
ments  sparingly  between  1890  and  1900,  more  generally  in  the  next  decennium, 
and  can  hardly  be  considered  to  have  exercised  a  controlling  influence  on 
public-health  administration  in  Baltimore  or  in  the  average  municipality  before 
1910.  Indeed,  it  would  be  difficult  to  select  another  branch  of  municipal 
government  on  which  scientific  discoveries  of  corresponding  importance  could 
have  exerted  in  so  leisurely  a  manner  an  influence  proportionate  to  their  value 

It  has  been  shown  that  long  before  the  discoveries  of  modern  micro-para¬ 
sitology  man  possessed  means  and  methods  capable  of  being  used  to  effect 


112  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

considerable  control  over  the  febrile  diseases;  that  the  placing  of  the  old 
germ  theory  of  the  causation  of  these  diseases  upon  a  firm  scientific  basis  was 
not  the  essential  or  determining  cause  of  the  modern  advances  in  public- 
health  activities,  and  that  this  practice,  as  regards  the  contagious  diseases, 
begun  in  the  fourteenth  century  in  Italy,  was  transplanted  to  England  in  the 
early  eighteenth  century,  and  that  in  England  and  elsewhere,  particularly  in  the 
United  States,  during  the  latter  part  of  the  eighteenth  and  the  whole  of  the 
nineteenth  centuries,  municipalities  attacked  the  effluvial  or  nuisance  diseases 
with  considerable  success,  and  that  the  contactive  diseases  in  general  have,  on 
the  whole,  been  attacked  with  a  much  smaller  degree  of  success  than  the 
nuisance  diseases.  A  consideration  of  general  history  and  of  the  knowledge 
of  the  natural  history  of  the  febrile  diseases  indicates  conclusively  that  until 
modern  man  had  regained  his  intellectual  freedom,  out  of  which  sprang 
religious  and  political  freedom  and  wealth,  advances  in  public-health  adminis¬ 
tration  were,  and  in  the  nature  of  things  could  be,  but  slight,  and  significant 
progress  in  the  control  of  these  diseases  became  possible  only  when  in  the  latter 
half  of  the  nineteenth  century  knowledge  and  wealth  were  not  only  attained 
but  diffused.  Hence  the  following  generalizations  are  warranted : 

1.  The  change  in  man’s  attitude  toward  the  control  of  those  diseases  was 
the  direct  result  of  the  revolution  in  the  religious,  political,  educational,  and 
social  status  of  the  common  man,  proceeding  from  intellectual  freedom,  and 
the  effects  achieved  were  due  more  to  the  release  from  inhibitions  against  the 
use  of  existing  ideas  and  methods  than  to  the  sudden  acquirement  of  new  ones, 
and,  being  greatest  among  peoples  who  had  attained  this  freedom  in  the  highest 
degree,  were,  in  any  particular  place,  other  things  being  equal,  in  direct 
proportion  to  the  degree  of  freedom  obtaining. 

2.  There  is  a  direct  relation  between  the  diffusion  of  knowledge  and  wealth 
among  peoples  and  their  public-health  activities,  and  the  discoveries  resulting 
in  new  ideas  and  methods  applicable  to  disease  control  and  proceeding  from 
intellectual  activities  along  general  and  special  lines  in  consequence  of  intellec¬ 
tual  freedom  have  been  submitted  to  practical  application  earliest  and  in  the 
highest  degree  among  peoples  with  the  widest  distribution  of  knowledge  and 
wealth. 

3.  It  is  because  the  methods  of  control  applicable  to  them  are  more  imper¬ 
sonal  (involve  to  a  much  less  extent  intimate  supervision  and  restriction  of 
the  person  and  of  personal  activities)  and  because  they  can  be  so  markedly 
influenced  by  measures  so  largely  covered  by  the  expenditure  of  money  upon 
environment,  that  the  diseases  formerly  attributed  to  effluvia,  or  the  nuisance 
diseases,  including  those  now  known  to  be  spread  by  intermediate  hosts,  have 
been  and  are  yet  more  energetically  attacked  and  more  successfully  combated 
than  the  diseases  classed  as  contagious.  Such  control  as  has  been  attempted 
over  diseases  believed  to  be  spread  by  contact  has  been  determined  more  by 
horror  inspired  by  the  physical  deformities  or  the  mode  of  death  characteristic 
of  a  disease  than  by  its  fatality.  The  attempts  to  control  the  former  class  of 
diseases  by  prevention  and  abatement  of  nuisances  were  logical  and  in  the 
right  direction,  and  the  failure  to  secure  better  results  was  due  in  greater 
degree  to  lack  of  effective  action  on  conclusions  reached  than  to  defects  in 
the  premises  set  up  on  assumptions  and  the  deductions  drawn  therefrom. 
The  one-sidedness  in  the  activities  of  public-health  administration  in  concen- 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


113 


trating  attention  so  closely  during  the  nineteenth  century  upon  the  nuisance 
diseases  is  responsible  for  the  present  widespread  and  deeply  rooted  belief,  on 
the  part  of  both  the  public  and  their  administrative  officials,  that  all  febrile 
diseases  can  be  effectively  controlled  by  modifications  of  environment. 

4.  As  the  methods  of  substitution  inoculation  against  small-pox  were  known 
and  practiced  long  before,  and  as  the  prevention  of  wound  infection,  includ¬ 
ing  puerperal  fever,  depends  so  much  more  upon  measures  directed  to  things 
and  to  the  control  of  the  acts  of  personal  attendants  than  upon  control  of 
persons  affected,  it  may  be  accepted  as  an  established  fact  that,  with  the 
exception  of  a  few  acute  diseases  for  which  they  have  furnished  methods  of  early 
diagnosis  and  of  preventive  inoculation,  such  as  diphtheria,  meningitis,  and 
hydrophobia,  modern  medical  discoveries,  including  those  of  micro-parasitology, 
have  exercised  as  yet  no  fundamentally  important  influence  upon  the  control  of 
the  diseases  classed  as  contagious,  for  any  recently  favorable  fluctuations  in  their 
incidence  and  mortality  can  be  adequately  explained  by  other  factors. 

o.  As  modernly  acquired  knowledge  has,  for  the  control  of  the  mass  of 
diseases  classed  as  contagious,  added  as  yet  comparatively  little  in  principle 
to  Mead’s  recommendations,  it  is  evident  that  in  respect  to  them  the  only 
change  introduced  in  public  health  practice  in  recent  times  is  the  attempt 
to  apply  these  measures  in  a  more  thorough  and  systematic  manner.  Though 
it  has  been  possible  under  very  favorable  circumstances  to  check  small  out¬ 
breaks  by  their  use,  or  here  and  there,  under  ordinary  conditions,  to  restrict 
the  numbers  attacked,  rarely,  if  ever,  with  the  exceptions  above  noted,  have 
any  of  the  diseases  classed  as  typically  contagious  been  curbed  when  in  epi¬ 
demic  cvcle. 

i/ 

It  is  to  be  clearly  understood  that,  in  connection  with  the  foregoing  state¬ 
ments,  there  is  no  intent  to  disparage  in  any  way  the  remarkable  and  pro¬ 
foundly  important  discoveries  in  modern  medicine  and  in  the  fundamental 
sciences,  particularly  in  mathematics,  physics,  chemistry,  zoology,  and  botany, 
on  which  it  depends,  and  in  the  applied  sciences  of  engineering,  statistics, 
genetics,  and  so  forth,  on  which  our  knowledge  of  the  natural  history  of  diseases 
is  so  largely  based  and  to  which  public-health  administration  owes  so  much,  and 
in  all  of  which  discoveries  have  been  gained  for  knowledge  by  a  comparatively 
small  band  of  self-sacrificing,  devoted,  and  often  brilliant  workers,  laboring 
only  too  often  under  unbelievable  handicaps.  No  one  who  has  grown  up 
under  the  influence  of  this  rapid  unfolding  of  scientific  knowledge,  the  most 
precious  possession  of  man,  especially  in  the  biological  sciences,  during  the 
last  40  years,  or  who  has  taken  even  a  small  part  in  its  development,  can  fail 
to  appreciate  its  importance  and  significance  both  generally  and  in  the  fields 
of  the  natural  history  of  disease  and  of  the  development  and  administration 
of  public-health  measures. 

To  point  out  that  it  was  not,  as  was  erroneously  supposed  in  many  quarters, 
the  acquisition  of  a  particular  branch  of  this  knowledge,  but  the  possession  and 
diffusion  of  knowledge  previously  gained,  to  which  recent  interest  and  progress 
in  public-health  activities  are  to  be  attributed  is  not  to  deny  its  great  value. 
The  sloth  with  which  modern  medical  knowledge,  and  especially  micro-para¬ 
sitology,  has  been  utilized  is  the  result  of  the  lack  of  proper  appreciation  by 
peoples  and  their  representatives,  and  in  no  way  reflects  upon  its  intrinsic 
value. 


114  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

Without  the  firm  standing-ground  of  the  exact  scientific  knowledge  gained 
in  this  period,  it  would  not  be  possible  to  recognize  that  previous  generations 
possessed  powerful  weapons  for  the  control  of  certain  diseases  or  to  appreciate 
how  signally  they  fell  short  of  their  full  use,  nor,  on  the  other  hand,  could 
a  just  estimate  be  had  of  how  much  was  accomplished  by  the  application  of 
methods,  sound  in  many  respects,  but  based  upon  theories  exploded  by  this 
knowledge. 

The  diseases  classed  by  the  health  authorities  and  by  the  physicians  generally, 
in  Baltimore,  from  the  earliest  times  until  the  last  decade  of  the  nineteenth 
century  as  infectious,  miasmatic,  or  effluvial,  and  therefore  as  nuisance  diseases, 
were  malarial  and  yellow  fevers,  membranous  croup  and  malignant  sore  throat 
(diphtheria),  and  the  diarrhoeal  diseases,  including  dysentery,  cholera  asiatica, 
cholera  morbus,  cholera  infantum,  simple  diarrhoea,  and  typhoid  fever. 

Among  the  typically  contagious  diseases  were  included  small-pox  and 
varioloid,  vaccinia,  scarlatina,  measles,  whooping-cough,  mumps,  erysipelas, 
typhus  fever,  influenza,  pulmonary  tuberculosis,  leprosy,  hydrophobia,  men¬ 
ingitis,  poliomyelitis,  and  the  venereal  diseases.  Tetanus,  though  not  made 
reportable,  was  included  by  inference  during  the  time  of  its  greatest  recorded 
prevalence  among  the  diseases  influenced  by  accident.  Diphtheria,  by  consensus 
of  opinion,  was  transferred  from  the  nuisance  to  the  contagious  diseases  during 
the  ninth  decade  of  the  nineteenth  century.  It  was  not  until  well  after  1890 
that  such  diseases  of  rare  occurrence  as  anthrax,  glanders,  actinomycosis,  and 
trichinosis  were  recognized  in  the  department. 

The  idea  that  some  of  these  diseases  may  be  spread  in  any  one  of  several 
ways,  obvious  as  it  seems,  did  not  occur  to  the  authorities  until  comparatively 
recent  times,  and  then  only  very  gradually. 

So  firmly  is  the  division  of  the  febrile  diseases  fixed  and  interwoven  into 
these  two  distinct  classes  in  the  conceptions  and  methods  of  the  health  and 
other  departments  of  the  Baltimore  City  government,  that  any  complete  study 
of  the  methods  and  results  of  its  public-health  administration  must  be  based 
primarily  upon  them.  Therefore,  the  study  of  the  administrative  efforts  of  the 
Baltimore  City  government  to  control  febrile  diseases  within  the  city  must 
embrace :  ( 1 )  measures  of  nuisance  prevention  and  abatement  directed  against 
nuisance-borne  diseases,  and  (2)  measures  of  restriction  and  inoculation 
directed  against  contagious  diseases. 

MEASURES  OF  NUISANCE  PREVENTION  AND 
ABATEMENT  DIRECTED  AGAINST 
NUISANCE-BORNE  DISEASES. 

The  term  nuisance ,  as  here  used,  includes  all  those  conditions  hurtful  or 
injurious  to  health,  which  originate  or  propagate  in  man’s  environment. 
Nuisances  in  this  sense  are  of  two  broad  classes :  Those  inherent  in  the  physical 
characteristics  of  a  place  and  those  brought  about  by  man’s  own  acts  or  negli¬ 
gence.  Examples  of  the  first  class,  which  may  be  properly  styled  nuisances  of 
location,  include  marshes,  ponds,  streams,  and  ravines.  Nuisances  of  the 
second  class  fall  into  five  categories :  Those  due  to  artificial  changes  in  the  con¬ 
tour  of  the  surface  of  the  ground,  which  interfere  with  the  natural  flow  of  water 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


115 


and  favor  the  accumulation  of  dirt  (brought  about  generally  by  excavations, 
changes  in  grades,  dams,  and  irregularities  of  street  surfaces,  and  so  forth)  ; 
those  arising  from  imperfect  methods  of  disposal  of  organic  waste  materials 
(such  as  the  excreta,  in  the  broadest  sense,  of  man  and  domestic  animals,  gar¬ 
bage,  offal,  street  sweepings,  and  lack  of  cleanliness  of  persons  and  of  clothes,  by 
which  food,  drink,  and  air  are  contaminated,  or  in  which  lower  organisms 
capable  of  acting  as  carriers  of  pathogenic  micro-organisms  are  bred  and 
supported) ;  those  concerned  directly  with  foods  (decayed  foods,  foods  from 
diseased  animals  or  plants,  and  foods  inadequate  in  themselves) ;  those  asso¬ 
ciated  with  buildings  in  which  man  works  or  lives ;  and,  finally,  those  connected 
with  the  things  with  which  man  works. 

Nuisances  of  either  class  may  be  present  upon  either  public  or  private 
domains.  In  Baltimore  the  topography  of  the  location  not  only  gave  rise  to 
numerous  nuisances  of  the  first  class,  but  rendered  the  prevention  and  abate¬ 
ment  of  nuisances  of  the  second  class  both  difficult  and  expensive.  Had  the 
town  been  located  on  the  high  ground  and  grown  toward  the  water,  or  had  the 
whole  area  been  graded  in  the  beginning  for  the  laying  out  of  a  large  city, 
its  nuisance  problems  would  have  been  comparatively  simple  and  its  whole 
sanitary  history  would  have  been  different.  As  it  is,  the  town  was  planted  on 
low  grounds,  it  was  bordered  on  three  sides  by  marshes,  through  which  flowed 
streams  subject  to  overflow,  and  on  the  fourth  side  it  was  overlooked  by  hills 
separated  by  ravines.  Since  the  low  ground  was  settled  first,  only  part  of  the 
material  obtained  in  grading  the  hills  was  utilizable  for  filling  the  low-lying 
section,  through  or  over  which  the  surface  water  had  to  flow.  The  work  of 
grading  both  sections  and  of  filling  and  raising  the  lower  portion  of  the  city 
along  the  water-front  and  the  four  streams  was  expensive  and  difficult.  In  the 
nature  of  the  case,  the  problems  could  be  worked  out  only  slowly.  It  is  clear 
that  the  main  questions  presented  embraced  an  abundant  and  safe  water-supply ; 
the  collection  and  diversion  of  the  flow  of  all  household  waste,  including 
excreta,  to  the  southeast;  grading,  filling,  and  paving;  the  construction  of 
conduits  to  lead  surface-water  to  the  water-front  and  to  prevent  standing  water ; 
the  removal  and  disposal  of  garbage,  ashes,  and  other  waste;  and  the  develop¬ 
ment  and  practice  of  decent  household  and  municipal  housekeeping.  The 
remainder  is  simple.  None  of  these  matters  has  ever  been  brought  to  com¬ 
pletion,  and  the  whole  history  of  nuisance  control  represents  a  series  of  discon¬ 
nected,  bungling  efforts  to  attain  an  impossible  goal.  In  actual  practice  these 
efforts  were  directed  simultaneously  against  both  classes  of  nuisances,  and  the 
only  clear-cut  division  of  nuisances,  from  the  standpoint  of  administration,  is 
into  nuisances  on  public  and  nuisances  on  private  domains.  Even  here  there 
is  some  overlapping.  As  closely  as  circumstances  will  allow,  nuisances,  however 
arising,  will  be  considered  under  these  two  headings. 

I.  PREVENTION  AND  ABATEMENT  OF  NUISANCES 

ON  PUBLIC  PROPERTY. 

DREDGING  AND  FILLING. 

The  dredging  of  the  basin  and  the  mouths  of  the  main  streams,  especially 
Jones  Falls  and  Harford  Run,  has  been  executed  in  general  by  the  city 
commissioners,  the  port  wardens,  or  the  harbor  board.  To  these  authorities  also 


116  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

has  fallen,  in  the  main,  the  duty  of  filling  the  marshes,  particularly  those  bor¬ 
dering  on  these  two  streams,  and  for  this  the  dredged  material  has  largely  been 
used.  Similarly,  authorities  other  than  the  Health  Department  have  had  charge 
of  sewer  building,  and  the  walling  in  and  the  covering  of  the  four  streams. 
The  health  authorities,  so  long  as  they  were  responsible  for  the  disposal  of  ashes 
and  rubbish,  used  these  for  filling  in  low  grounds  on  public  as  well  as  on 
private  domains. 

GRADING  AND  PAVING. 

On  account  of  the  topography  of  Baltimore,  the  amount  of  grading  necessary 
in  the  laying  out  of  streets  and  the  filling  of  low  grounds  was  considerable.  In 
the  early  days  of  the  city’s  growth,  the  filling  in  of  the  marshy  land  along 
the  water-front,  especially  bordering  the  course  of  the  four  streams,  Harford 
Run,  Jones  Falls,  and  Schroeder’s  and  Chatsworth’s  Runs,  comprised  the  chief 
grading  activities.  Much  of  the  material  for  this  purpose  was  dredged  from  the 
basin  and  the  mouths  of  the  streams.  Later,  with  the  growth  of  the  city  to 
the  north  beyond  Saratoga  Street,  and  west  and  east,  a  series  of  high  and 
irregular  hills  were  cut  through  and  smoothed  off,  and  the  valleys  between 
them  raised.  This  required  an  enormous  amount  of  labor.  The  margin  of  the 
built-up  section  has  always  presented  a  number  of  ravines  to  be  filled.  For 
this  purpose  soil  obtained  from  leveling  and  from  the  excavations  for  buildings 
and,  of  late  years,  coal  ashes  and  cinders,  have  been  used.  In  this  way  the 
use  of  ravines  and  other  low  places,  with  which  the  border  of  the  city  has 
always  abounded,  as  public  dumps,  has  done  away  with  many  nuisances  and  has 
been  of  material  assistance  in  grading. 

As  early  as  1782  the  grading  and  paving  of  the  streets  and  sidewalks  was 
undertaken  in  a  systematic  manner  under  the  direction  and  control  of  a 
special  commission  established  for  the  purpose  by  the  legislature.  At  this  time, 
Market  or  Baltimore  Street,  the  main  thoroughfare,  was  in  a  deplorable  con¬ 
dition  and  in  wet  weather  was  almost  impassable.  The  street  pavements,  at 
first  confined  to  the  business  sections,  were  of  rough  cobblestones,  set  in  sand 
on  top  of  the  clay  soil.  By  an  ordinance  in  1819,  all  future  paving  was  to  be 
done  with  river  or  pebble  stone  (called  cobblestone)  from  7  to  3  inches  in 
diameter  and  at  least  5  inches  in  length,  set  upright  in  a  bed  of  sharp  sand 
at  least  1  foot  in  depth.  Until  1910,  except  where  Belgian  blocks  (granite 
blocks)  and  occasionally  asphalt  were  substituted  in  a  few  business  streets  and 
prominent  thoroughfares,  the  typical  cobblestone-paved  street  was  elevated  in 
the  center  and  sloped  to  the  sides,  which  were  bordered  by  gutters  laid  with 
smaller  and  flatter  cobblestones.  Set  in  sand  over  a  clay  base  and  with  poorly 
matched  stones,  these  pavements  under  heavy  traffic  developed  larger  and 
smaller  holes  in  which  water  and  organic  materials  collected.  The  private 
alleys  (varying  in  width  from  3  to  18  or  20  feet)  which  intersect  every  block 
were  gradually  paved  with  cobblestones  in  most  of  the  closely  built  sections 
of  the  city.  These  pavements  were  concave  with  a  central  gutter  for  the  con¬ 
duct  of  storm-water  and  the  household  wash-water,  which  poured  into  it 
through  rough  and  for  the  most  part  open  drains  which  traversed  the  neighbor¬ 
ing  backyards.  As  these  pavements  were  often  poorly  laid  and  ill  adapted  to  sup¬ 
port  the  heavy  garbage  and  ash  carts  that  passed  through  the  alleys,  they  soon 
became  full  of  holes,  in  which  collected  stagnant  water,  garbage,  and  stable 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


117 


manure.  In  many  parts  of  the  city  the  alleys  were  catch-basins  of  filth,  for  into 
them  were  deposited  garbage  and  ashes  for  collection  and  all  sorts  of  household 
rubbish.  The  condition  of  the  unpaved  alleys  was  worse.  The  alleys,  except 
when  they  have  occasionally  been  taken  over  by  the  city,  are  private,  belonging 
to  the  owners  of  the  adjacent  properties  along  the  rear  or  side  of  which  they 
run,  and,  therefore,  their  paving  is  at  the  expense  of  the  owners. 

The  report  of  the  city  engineer  in  1911  gave  the  street  mileage  of  the 
different  kinds  of  pavements  as  follows:  Cobblestone,  354.82;  Belgian  block, 
43.49;  sheet  asphalt,  19.23;  vitrified  brick,  19.15;  wooden  block,  1.63;  ordi¬ 
nary  macadam,  56.01:  bituminous  macadam,  2.73;  bitulithic,  10.10;  cement 
surface,  2.01;  unpaved  57.73.  Thus  of  the  total  mileage  62.5  per  cent  was 
cobblestone,  and  of  the  total  mileage  of  what  may  properly  be  called  street 
pavement  (excluding  the  ordinary  macadam  and  the  unpaved  streets),  78  per 
cent  was  cobblestone. 

During  the  early  days  of  the  city’s  history,  the  sidewalks  were  largely  of 
brick,  retained  at  the  gutter  side  by  a  curbing  of  granite.  Of  late  years,  cement 
has  been  generally  used,  and  much  of  the  former  brick  paving  has  been  replaced 
with  this  material. 

Since  1912,  under  the  stimulus  of  Mayor  James  H.  Preston  and  following 
the  construction  of  the  new  sewerage  system,  many  miles  of  streets  have  been 
regraded  and  paved  with  smooth  pavements,  edged  by  well  designed  and  con¬ 
structed  gutters  with  smooth  surfaces. 

In  1916  and  1917,  all  of  the  nearly  3,000  roughly  paved  private  alleys  were 
condemned  as  nuisances  by  the  health  department  and  ordered  regraded  and 
paved  with  smooth  pavements  by  the  highways  engineer  at  the  expense  of 
the  owners.  When  this  work  was  suspended  during  1918  on  account  of  the 
war,  this  undertaking  had  been  completed  in  about  half  of  these  alleys. 

STREET  CLEANING  AND  GARBAGE  REMOVAL. 

Since  the  passage  of  Ordinance  15  in  1797,  it  has  been  the  duty  of  the 
owners  or  occupiers  of  houses  and  lots  within  the  city  to  keep  the  sidewalks 
clean  and  the  gutters  clear,  and  it  has  been  the  function  of  the  city  government 
to  clean  the  streets  or  public  highways  and  to  remove  the  sweepings.  The  latter 
duty  was  exercised  under  the  direction  of  the  city  commissioners  until  1826, 
when  it  was  transferred  to  the  commissioners  of  health.  In  1882  it  was  taken 
over  by  a  newly  created  department  of  the  city  government,  the  department  of 
street  cleaning. 

It  is  not  certain  when  the  removal  of  garbage  and  ashes  was  first  undertaken 
by  the  city.  It  is  probable,  however,  that  until  1821  each  householder  made  his 
own  arrangements  for  this  purpose,  and  it  is  likely  that  it  was  fed  to  pigs 
within  the  city.  In  1821  the  city  undertook  the  removal  of  garbage  and  ashes, 
and  the  superintendents  of  street  cleaning,  offices  established  in  1798  under 
the  city  commissioners,  were  required  by  ordinance  to  collect  garbage  on  three 
days  of  each  week  between  May  1  and  November  1,  and  from  this  time  the 
removal  and  disposal  of  garbage  and  ashes  have  been  conducted  under  which¬ 
ever  department  of  the  city  government  was  responsible  for  street  cleaning. 

In  1826,  the  commissioners  of  health  let  out  the  cleaning  of  the  streets  and 
the  removal  of  garbage  by  contract.  The  total  sum  appropriated  to  the  health 


118  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

department  for  these  purposes  in  1827  was  $3,500.  Since  1828,  the  manure 
obtained  from  the  streets  has  been  sold,  and  the  income  from  this  source  in 
considerable  part  paid  for  the  work.  Thus,  in  1820,  of  $5,500  available  for 
those  services,  $1,500  was  derived  from  the  sale  of  manure. 

It  is  related  by  Wynne  that  in  1849  the  city,  for  purposes  of  street  cleaning, 
was  divided  into  five  districts,  the  cleaning  of  each  of  which  was  let  to  separate 
contractors.  Each  contractor  received  in  payment  the  street  refuse,  which  was 
sold  as  manure,  and  about  $1,000  in  money. 

The  streets  received  attention  in  proportion  to  their  tendency  to  collect 
filth,  but  never  more  than  twice  a  week,  and  more  usually  once  in  two  weeks. 
The  numerous  narrow  alleys  and  courts,  inhabited  by  the  poor  and  the  deposi¬ 
tories  of  garbage  and  worse,  received  little  attention  and  were  generally  in  a 
filthy  condition.  The  most  effective  scavengering  in  these  districts  was  per¬ 
formed  by  swine,  which  roamed  through  them  at  pleasure.  The  most  effective 
street  cleaning  was  performed  by  the  copious  showers,  which  were  most  fre¬ 
quent  in  summer. 

In  1853,  the  contract  system  of  the  cleaning  of  streets  and  the  removal  of 
garbage  and  ashes  was  abandoned,  and  these  services  were  taken  over  by  the 
commissioner  of  health,  Mr.  Charles  A.  Leas,  who,  judged  by  his  detailed 
reports  and  his  recommendations,  was  an  engineer  of  ability.  His  report  of 
1853  is  the  first  from  which  it  is  possible  to  form  any  accurate  idea  of  the 
amount  of  work  done  and  of  how  it  was  accomplished.  In  the  last  nine  months 
of  this  year  there  were  removed  43,576  cartloads  of  street  sweepings  at  a  net 
cost,  after  the  sale  of  the  manure,  of  14.5  cents  a  load,  and  21,642  loads  of 
garbage  at  a  cost  of  43.5  cents  a  load.  The  total  actual  cost  to  the  city,  exclusive 
of  sweeping  the  streets,  of  the  removal  of  65,218  loads  was  $16,586.19.  There 
were  26  carts  to  remove  garbage  from  30,000  houses ;  i.  e.,  each  cart  had  to 
collect  from  1,154  houses,  daily  in  summer  and  biweekly  in  winter. 

Mr.  Leas  proposed  a  permanent  garbage-disposal  place  on  a  farm  owned 
by  the  city,  which  would  be  served  by  boats  and  where  the  garbage  would  be 
fed  to  pigs.  This  piggery,  he  thought,  would  in  a  few  years  yield  a  return 
sufficient  to  pay  all  the  expenses  of  garbage  removal.  Unfortunately  his  plan 
was  not  adopted. 

A  decided  step  forward  was  taken  in  1876,  when  householders  were  required 
by  ordinance  to  keep  garbage  and  ashes  separate,  in  order  that  the  latter  might 
be  used  to  fill  in  low  places  within  the  city.  The  garbage  and  other  offal 
were  hauled  to  convenient  lots  near  the  outskirts  of  the  city  and  placed  on 
large  dumps  until  1877,  when  a  new  policy  was  adopted  of  delivering  it  to 
contractors,  who  removed  it  by  rail  or  by  barge  to  points  not  less  than  6 
miles  from  the  city  limits.  This  change  of  method  of  removal  was  forced  on 
the  city  by  threats  of  suits  on  the  part  of  the  inhabitants  of  Baltimore  County. 

In  1880,  26,252  loads  of  garbage  were  delivered  at  the  contractors’  dumps 
at  Canton  and  Spring  Gardens,  and  for  transporting  this  the  contractors  were 
paid  51.5  cents  a  load. 

Between  1904  and  1919,  the  garbage  so  conveyed  was  “  reduced  ”  by  con¬ 
tractors,  and  in  the  latter  year  arrangements  were  made  with  a  contractor  to 
feed  the  garbage  to  pigs  at  a  farm  fitted  for  this  purpose  on  the  water-front 
well  below  the  city.  Thus  after  66  years,  Commissioner  Leas’s  plan  of  garbage 
disposal,  somewhat  modified,  was  adopted. 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


119 


In  1917,  the  number  of  cubic  yards  of  garbage  hauled  by  the  city  was 
113,162;  of  ashes  and  refuse,  425,307;  of  street  dirt,  225,224;  of  sewer  and 
inlet  dirt,  13,760;  and  of  snow  and  ice,  136,542;  a  total  of  913,995.  Dead 
animals  removed  numbered  20,178. 

The  work  in  connection  with  the  control  of  mosquitoes  is  set  forth  in  table  4. 


Table  4. 


House  inspections  .  114,414 

Breeding-places  found  and  de¬ 
stroyed  .  3,984 

Circulars  distributed  .  115,717 

Notices  sent  out .  5,259 

House  inspectors,  daily  average...  26 

Men  employed,  weekly  average . . .  285 

Pools  drained .  143 

Old  ditches  cleaned,  graded,  filled, 

or  oiled,  feet . 1,144,595 

New  ditches  constructed,  feet....  16,133 


Toilets  reported  overflowing  or  in 

need  of  attention .  2,220 

Complaint  cards  turned  in  bj'  em¬ 
ployees  .  324 

Premises  and  other  unsanitary  con¬ 
ditions  reported  to  city  depart¬ 
ments  .  3,439 

Improper  garbage  cans  reported  to 

police  department  .  6,337 

Gallons  of  larvacide  solution  used.  5,855 

Gallons  of  oil  solution  used .  7,176 

Gallons  of  kreso  used .  50 


The  total  expenditure  of  the  department  for  1917  was  $876,093.02,  including 
$25,897.73  spent  on  the  work  of  mosquito  control.  From  the  sale  of  refuse, 
$12,729.10  were  realized. 

SEWERAGE. 

Sewerage  will  be  considered  under  three  headings :  First,  storm-water ; 
second,  household  water,  that  is,  toilet,  wash,  and  kitchen  waste ;  third,  human 
and  animal  excreta,  slaughter-house  waste  and  other  wastes  exclusive  of  garbage. 

Until  1915,  storm-water  and  household  water  were  disposed  of  in  the  same 
way,  that  is,  by  natural  flow  into  the  water-courses  traversing  the  city  and 
ultimately  into  the  harbor,  basin,  and  the  middle  branch  of  the  Patapsco  River. 
As  the  city  grew  and  made  a  large  area,  which,  on  account  of  the  houses  and 
street  pavements,  was  impervious  to  water,  the  storm-water  thus  to  be  disposed 
of  very  greatly  increased  in  volume.  As  a  result,  the  low-lying  sections  of  the 
city,  particularly  the  narrow  valleys,  were  often  flooded,  and  with  the  subsidence 
of  the  water  they  were  left  covered  with  a  large  amount  of  silt  and  street  and 
household  washings,  including  manure,  grease,  and  garbage.  The  large  rain¬ 
fall  served  to  keep  the  higher  and  hilly  sections  fairly  clean  and  took  much  of 
their  dirt  to  the  low-lying  portions.  For  the  same  reasons,  the  water-courses, 
often  in  a  state  of  flood,  would  overflow  their  banks  and  further  add  to  the 
filth  in  the  lower,  flat  portions  of  the  city.  The  land-locked  basin,  the  harbor, 
and  Spring  Gardens,  to  a  lesser  extent,  thus  in  the  course  of  time  became 
loaded  with  organic  waste,  the  putrefaction  of  which  in  warm  weather  gave 
rise  to  very  offensive  odors  which  were  a  constant  source  of  annoyance.  The 
same  streams,  first  at  their  mouths  and  later  throughout  their  courses  within 
the  city,  became  foul,  ill-smelling  sewers,  giving  off  offensive  gases  in  hot 
weather.  Of  these,  the  foulest  were  Jones  Falls  and  Harford  Run.  The  storm¬ 
water  gutters  in  the  streets  and  alleys,  being  rough  and  irregular  and  often 
improperly  graded  in  many  places,  formed  pools  of  water  containing  organic 
material.  These  were  particularly  offensive  in  the  narrow  courts  and  alleys  of 
the  poorer  sections,  from  which  drained  every  conceivable  kind  of  organic 
waste  and  other  filth.  In  1850  there  were  about  2  miles  of  storm-water  sewers 
in  the  whole  city. 


120  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

The  first  serious  consideration  of  the  sewerage  question  on  the  part  of  the  city 
government  was  in  1859,  when  a  sewerage  commission  of  three,  under  the  chair¬ 
manship  of  Henry  Tyson,  was  appointed.  In  its  report  made  in  1862,  the  com¬ 
mission  recommended  the  establishment  of  eight  sewerage  districts  in  which 
sewers  were  to  be  built  to  carry  off  storm-wTater  and  household  waste-water, 
exclusive  of  human  excreta,  more  readily  along  the  natural  drainage  lines. 
The  commission  pointed  out  that  in  building  the  sewers  then  existing  in 
Baltimore,  no  particular  form  or  system  of  size  had  been  adopted  and  that  in 
but  few  instances  could  they  be  exactly  located.  They  often  ran  a  winding 
course,  the  bottoms  were  nearly  always  flat;  some  were  floored  with  plank 
which  had  decayed  and  left  the  original  earth  bottom  protected  from  washings 
only  by  the  accumulation  of  stone  and  other  heavy  substances  which  had  washed 
into  them.  Some  sewers  were  roughly  paved  with  stone;  in  all  of  them  the 
free  flow  of  water  was  greatly  impeded;  and  during  dry  weather  the  surface- 
water  and  house  drainage,  spread  irregularly  over  the  surface,  wTere  either 
absorbed  by  the  earth  or  evaporated,  leaving  heavy  animal  and  vegetable  sub¬ 
stances  to  decay  in  the  sewers,  resulting  in  offensive  effluvia  arising  from  the 
open  and  untrapped  inlets.  In  some  of  the  sewers,  side  walls  only  had  been 
built  to  confine  the  water  course,  and  they  were  planked  over  at  the  street 
crossings ;  otherwise,  the  floors  of  the  houses  built  over  them  formed  their  sole 
covering.  The  commission  recommended  the  building  of  a  series  of  sewers  with 
well  constructed  and  trapped  inlets  to  carry  off  the  house  drainage  and  surface- 
water  from  the  eight  districts  above  mentioned,  and  planned  to  lead  the 
tributary  sewers  or  laterals  either  into  the  main  water-courses  which  were  to 
be  covered  over  eventually  or  through  covered  sewers  directly  into  the  harbor 
and  basin.  As  this  drainage  was  to  go  into  the  harbor  and  basin,  they  thought 
it  unwise  to  include  human  waste.  This  they  planned  to  dispose  of  into  the 
ground  in  cesspools  as  before.  These  recommendations  were  carried  out  in 
part  somewhat  slowly,  and  largely  under  the  pressure  of  the  health  department 
for  the  abatement  of  nuisances.  Harford  Run  was  not  covered  over  until  1885, 
and  Jones  Falls  was  covered  over  through  a  part  of  its  course  in  1912. 

Mr.  C.  H.  Latrobe,  C.  E.,  who  had  been  appointed  by  the  city  council  to 
report  on  the  best  plan  for  sewerage  disposal,  rendered  an  interesting  report 
in  August  1881.  Recognizing  that  the  subsoil  had  reached  the  limit  of  its 
capacity  to  care  for  human  excreta  by  the  cesspool  and  privy  systems,  he  recom¬ 
mended  a  dual  sewerage  system;  one  for  surface-water  and  rainfall,  to  dis¬ 
charge  as  before  into  the  middle  branch  of  the  Patapsco,  the  basin,  and  the 
harbor,  and  the  other  for  household  waste  and  human  excreta,  to  discharge 
partly  into  the  middle  branch  of  the  Patapsco  and  partly  into  the  lower 
harbor  below  Canton.  His  recommendations  for  sanitary  sewers  were  entirely 
passed  over  and  the  construction  of  storm-water  sewers  was  continued  along 
the  lines  of  the  plans  of  the  Tyson  commission,  somewhat  modified  by  the 
recommendations  of  Mr.  Latrobe. 

By  1890,  owing  to  the  great  increase  in  the  number  of  cesspools,  many  of 
which  had  been  connected  to  the  old  and  to  new  storm-water  sewers  and  drained 
directly  into  the  basin,  harbor,  and  the  middle  branch  of  the  Patapsco,  and  to 
the  fact  that  many  of  these  sewers  were  improperly  trapped,  conditions  had 
become  much  worse.  The  uncovered  Jones  Falls  was  to  a  great  degree  a  com¬ 
bined  storm-water  and  sanitary  sewer,  carrying  so  much  filth  that  it  was  con- 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


121 


stantly  necessary  to  dredge  its  lower  portion  for  the  removal  of  sediments  of 
organic  matter.  For  40  years  or  more  the  sulphuretted  hydrogen  gas  evolved 
from  the  sewers  and  the  basin,  with  favorable  wind  conditions,  reached  all 
parts  of  the  city.  Large  quantities  of  sediment  of  sewer  origin  were  each  year 
dredged  from  the  basin  and  especially  from  between  the  docks  and  at  the 
sewer  outfalls. 

A  second  sewerage  commission,  under  the  chairmanship  of  Mr.  Mendes 
Cohen,  was  appointed  in  1893  and  engaged  Messrs.  Rudolph  Hering  and 
Samuel  M.  Gray  as  consulting  engineers  and  Mr.  Kenneth  Allen  as  assistant 
engineer.  After  an  exhaustive  study,  the  commission,  in  its  report  of  Septem¬ 
ber  1897,  recommended  a  dual  sewerage  system,  the  storm -water  to  be  dis¬ 
charged  as  recommended  before,  and  the  domestic  waste,  including  human 
excreta,  to  be  disposed  of  by  dilution  into  the  deep  waters  of  the  Chesapeake 
Bay,  well  below  the  city.  Of  the  two  alternative  methods  proposed  by  the 
engineers,  i.  e.,  chemical  precipitation  before  such  discharge  and  the  use  of 
filtration  beds  on  land  in  Anne  Arundel  County,  they  objected  to  the  former 
as  unnecessary  and  to  the  latter  on  account  of  its  great  expense. 

The  city  government,  fearing  injury  to  the  fishing  industry,  particularly  on 
account  of  the  danger  of  infecting  oysters  with  typhoid  bacilli,  directed  further 
investigation  and  a  report  on  the  best  alternative  plan.  The  commission  then 
suggested  that  the  plan  of  land  filtration  be  tried,  but  be  restricted  at  first  to 
the  sewerage  from  the  low-level  area,  thus  serving  about  one-third  of  the  popula¬ 
tion.  The  whole  matter  was  then  dropped,  because  the  people  refused  to  approve 
a  bond  issue  to  pay  the  cost  of  the  work. 

In  1905,  the  third  sewerage  commission  was  appointed.  Messrs  Hering, 
Gray,  and  Stearns  served  as  a  board  of  consulting  engineers,  and  Mr.  Calvin 
W.  Hendrick  was  appointed  chief  engineer.  Mr.  Hendrick  and  his  staff  designed 
and  superintended  the  building  of  a  double  system  of  sewers — surface-water  and 
sanitary — covering  most  of  the  built-up  sections  of  the  city.  The  surface-water 
sewers  discharge  the  storm-water  as  before.  The  sanitary  sewers  carry  domestic 
waste  and  human  excreta  to  a  point  on  Back  River,  to  the  southeast  of  the  city, 
where  the  sewerage  is  purified  and  the  effluent  discharged  into  the  Bay.  The 
system  was  completed  in  1915.  Connections  were  started  on  a  limited  scale  in 
the  fall  of  1911  and  practically  all  of  the  connectable  buildings,  over  90,000  in 
the  sewered  area,  had  been  connected  by  1918. 

As  has  been  previously  indicated,  human  waste  was  disposed  of  throughout 
the  history  of  Baltimore  until  1915  either  by  privies,  cesspools,  or  storm -water 
sewers.  As  the  city  grew,  the  use  of  privies  decreased  and  the  cesspool  became 
the  usual  method.  As  a  rule,  every  dwelling  had  its  own  cesspool,  protected  by 
a  house,  situated  in  the  back  yard.  In  some  of  the  larger  houses  there  were 
closets,  situated  either  on  back  porches  or  within  the  houses,  leading  to  cess¬ 
pools,  located  either  in  the  yards  or  under  the  cellars.  At  what  date  water  was 
introduced  for  flushing  such  closets  in  Baltimore  is  unknown,  but  in  1849, 
according  to  Wynne,  this  practice  obtained  in  a  considerable  number  of  the 
better  class  dwellings. 

LTnder  the  description  of  the  water-supply,  allusion  is  made  to  the  partial 
protection  of  the  city  springs  against  contamination  by  privies  afforded  by 
the  ordinances  of  1817  and  1820.  To  what  extent  the  specifications  laid  down 
in  the  ordinance  of  1820  for  the  construction  of  water-tight  privies  in  the  prox- 


122  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

imity  of  the  city  springs  were  later  generally  extended  is  not  known.  While  there 
is  much  evidence  that  many  of  the  privy-wells  or  cesspools  in  connection  with 
the  better  class  of  houses  throughout  the  city  were  well  constructed  and  made 
water-tight — at  least  when  built — it  was  not  until  1891  that  an  ordinance  was 
passed  requiring  that  every  privy-well  or  cesspool  should  be  made  water-tight. 
The  typical  water-tight  cesspool  had  walls  9  inches  thick,  of  brick  set  in  cement, 
and  the  outside  was  well  puddled  with  clay.  At  one  time  barrels  or  hogsheads 
buried  in  the  ground  were  used  as  cesspools.  The  common  practice  in  certain 
parts  of  the  city,  until  forbidden  by  law  in  1906,  of  connecting  several  houses 
with  a  single  cesspool  was  a  frequent  cause  of  overflow.  Sanitary  nuisances 
from  privy-wells  or  cesspools  arose  in  several  ways.  In  the  first  place,  many 
were  not  properly  closed  at  the  top  and  in  consequence  emitted  disagreeable 
odors,  to  which  diseases  were  attributed,  and  attracted  and  fed  flies,  mosquitoes, 
rats  and  other  vermin.  In  the  second  place,  on  account  of  neglect  or  inaccessi¬ 
bility,  many  were  not  regularly  cleaned,  and  their  contents  overflowed  into 
cellars,  yards,  courts,  alleys,  and  streets.  In  the  third  place,  although  in  1821 
it  was  provided  that  all  privies  hereafter  constructed  on  docks,  wharves,  or 
made  ground,  and  all  other  privies  within  the  limits  of  direct  taxation  (built-up 
sections)  should  be  made  water-tight,  those  that  were  not  of  water-tight  con¬ 
struction  originally  and  those  that  were  water-tight  but  developed  breaks 
saturated  the  soil  and  polluted  the  springs  and  wells.  As  the  cesspools  were 
set  in  a  stiff  clay  soil,  much  of  this  material  made  its  way  to  the  surface  and 
thus  added  to  the  nuisance  from  overflow.  A  large  proportion  of  the  cesspools 
were  constantly  overflowing  into  cellars,  streets,  courts,  and  alleys,  and  created 
a  formidable  nuisance.  The  privies  and  cesspools  were  cleaned  out  by  night- 
soil  men,  who,  since  1798,  were  licensed  and  in  a  manner  supervised  by  the 
health  department,  but  employed  at  the  expense  of  the  householder.  This 
material  was  hauled  away  in  carts,  at  first  to  dumps  outside  of  the  city,  where 
it  was  sold  to  farmers,  and  later  to  scows  at  Folley’s  and  Winans’s  wharves, 
whence  it  was  carried  to  Bush  River  and  other  creeks  tributary  to  the  harbor 
and  sold  in  its  raw  state  to  farmers  or  manufactured  into  poudrette  to  be  sold 
as  fertilizer.  At  various  times,  with  and  without  the  permission  of  the  city 
government,  cesspools  were  connected  with  the  laterals  of  the  storm-water 
sewers.  The  chief  engineer  of  the  last  sewerage  commission  estimated  in  1910 
that  at  that  time  15,000  dwellings  had  been  discharging  in  this  way  into  the 
basin  and  harbor.  There  are  now  over  90,000  houses  connected,  and  in  most 
of  the  old  24  wards  the  privy  and  the  cesspool  have  been  eliminated.  Thus, 
the  opportunities  for  fly-borne  typhoid  must  have  been  greatly  restricted. 

Much  of  the  sanitary  sewerage  of  a  considerable  district  in  the  northwest 
and  southwest  sections  of  the  city  still  finds  its  way  into  Gwynn?s  Falls,  a 
stream  already  polluted  with  sewerage  before  it  reaches  city  limits.  As  the 
population  so  served  is  still  relatively  small  and  the  stream  is  large  and  rapid, 
the  insanitary  conditions  are  by  no  means  a  nuisance  comparable  to  those  which 
obtained  in  Jones  Falls,  or  in  Harford,  Chatsworth,  and  Schroeder’s  Runs  in 
former  days.  Jones  Falls  and  its  tributaries  as  well  still  receive  a  certain  but 
relatively  small  amount  of  sanitary  drainage  from  outlying  sections  of  the 
city.  The  same  may  be  said  in  regard  to  Herring  Run,  as  it  runs  through  the 
northeastern  part  of  the  city.  This  stream  is  already  polluted  from  sources 
to  the  north  of  the  city.  The  closely  built  up  Highlandtown,  bounding  the 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


123 


eastern  margin  of  the  city,  still  retains  to  a  large  degree  the  old,  primitive 
method  of  storm-water  and  sanitary  sewerage  disposal  which  obtained  in  the 
old  city  before  the  construction  of  the  new  sewerage  systems. 

In  review,  the  storm-water,  together  with  household,  laundry,  and  kitchen 
waste-water,  and  fluids  from  slaughter-houses,  stables,  and  factories,  was  from 
the  beginning  of  the  town  until  1912  very  inadequately  drained  by  gutters, 
through  and  over  the  streets,  lanes,  courts,  and  alleys,  into  the  basin,  harbor, 
and  the  middle  branch  of  the  Patapsco,  either  directly  or  by  means  of  the  four 
streams.  After  1860  a  considerable,  but  quite  inadequate,  number  of  storm¬ 
water  sewers  removed  some  of  this  drainage  from  the  streets.  The  storm-water 
also  carried  a  large  amount  of  garbage  and  street  dirt  and  manure.  As  the 
flow  was  much  impeded  by  the  irregular  and  rough  character  of  the  pavements 
of  both  streets  and  alleys,  accumulations  of  water  containing  organic  waste  were 
numerous.  Until  about  1870,  practically  all  the  human  waste  was  received  in 
earth  privies  or  in  cesspools  or  privy  wells.  After  this  date  a  considerably 
increasing  amount  of  this  material  was  discharged  either  by  private  sewers 
or  by  connections  with  the  storm-water  sewers  as  they  were  constructed.  By 
1910  about  15  per  cent  of  the  whole  amount  was  disposed  of  thus. 

In  certain  sections  of  the  city  to  which  the  new  sanitary  sewerage  system 
does  not  yet  extend  i.  e.,  a  portion  of  Locust  Point,  the  outlying  sections  on 
the  western  boundary  of  the  city,  some  portions  of  the  northwestern  section, 
and  most  of  the  Hampden- Woodberry  district,  old  methods  of  disposal  of 
human  excreta  are  still  in  vogue.  In  those  portions  of  the  city  bordering  on 
the  harbor,  it  is  discharged  directly  into  the  basin  or  into  the  middle  branch 
of  the  Patapsco;  in  the  western  and  northwestern  sections  it  is  disposed  of 
either  into  cesspools  or  into  GwymPs  Falls  and  thence  into  the  middle  branch 
of  the  Patapsco  by  connections  with  storm-water  sewers;  in  the  Hampden- 
Woodberry  district,  cesspools  are  still  numerous,  but  a  considerable  proportion 
of  the  human  waste  is  discharged  by  storm  water  or  by  private  sanitary 
sewers — in  some  cases  after  crude  forms  of  purification — leading  into  Jones 
Falls  and  thence  into  the  basin.  Similarly,  on  the  northeastern  side  of  the 
city,  much  of  the  newly  developed  section  is  without  sanitary  sewers  and  is 
served  temporarily  by  connections  with  storm-water  sewers  or  by  private 
sanitary  sewers — both  discharging  into  Harford  Bun  or  into  Herring  Bun, 
and  thence  into  the  basin  and  harbor.  The  aggregate  amount  of  the  material 
so  discharged  is  not  yet  sufficient  to  give  rise  to  disagreeable  odors,  and  as 
practically  all  the  wells  and  springs  in  the  old  24  wards  have  been  eliminated, 
this  method  of  disposal  has  been  no  great  menace  to  health.  Some  years  must 
elapse  before  the  plans  of  the  sewerage  division  to  reach  all  these  areas  with 
sanitary  sewers  are  carried  out. 

Throughout  the  history  of  the  city  until  the  completion  of  the  new  sewerage 
system,  the  overflowing  privy  and  the  disposal  of  night-soil  were  constant 
nuisances.  As  in  the  annexation  of  1888,  so  with  that  of  1919,  the  city  annexed 
a  large  territory,  much  of  which  is  without  sanitary  sewers. 

From  the  building  of  the  first  sewers  to  the  completion  of  the  new  sewerage 
system,  the  health  department  was  charged  with  the  sanitary  supervision  of 
the  sewers  and  was  responsible  for  cleaning  and  for  the  removal  of  obstructions. 
In  recent  years  the  care  of  the  traps  of  the  storm-water  sewers  has  been  a  duty 
of  the  street  cleaning  department,  and  the  whole  care  of  the  sanitary  sewers 

9 


124  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

from  the  disposal  plant  to  the  lines  of  private  property  has  rested  with  the 
sewerage  division  of  the  city  engineers*  department.  The  jurisdiction  of  the 
health  department  over  both  storm  and  sanitary  drainage  begins  with  the 
private  property  lines  and,  within  these,  remains  absolute. 

WATER. 

Until  1808,  the  water-supply  of  Baltimore  was  almost  entirely  of  intra¬ 
urban  origin  and  was  derived  from  springs  and  wells  and  perhaps,  to  a  small 
extent,  from  the  creeks  and  runs  traversing  the  territory  from  north  to  south 
and  emptying  into  the  harbor,  the  basin,  and  the  middle  branch  of  the  Patapsco 
River.  In  all  parts  of  the  city,  including  Old  Town  and  FelPs  Point,  natural 
springs  abounded.  As  the  town  and  city  grew,  many  of  these  springs  became 
no  longer  available,  due  to  the  encroachment  of  buildings.  The  earliest  spring 
now  known  to  have  been  in  general  use  was  the  Cool  Spring,  pictured  in 
Moale’s  sketch  of  Baltimore  Town  (1752),  situated  near  the  western  bank  of 
the  basin.  It  played  a  large  part  in  the  life  of  early  Baltimore,  both  as  a 
place  of  social  rendezvous  and  a  source  of  water  for  townspeople  and  for  ships. 
It  was  perhaps  the  same  spring  as  the  one  later  known  as  Clopper’s.  Some  of 
the  larger  springs  were  reserved  and  improved  for  public  use,  being  surrounded 
by  small  parks  or  squares  and  covered  with  attractive  “  spring-houses,”  which 
were  supported  by  pillars  and  ornamented  with  balustrades.  The  most  famous 
of  these  were  the  Eastern,  Western,  Center,  and  the  City  Fountains.  The 
Eastern  Fountain  was  situated  near  the  corner  of  East  Pratt  and  South  Eden 
Streets,  and  it  was  supplied  with  water  from  a  local  spring,  probably  Sterritt’s 
Spring,  purchased  by  the  city  in  1816.  The  tine  spring-house  with  Ionic 
columns  was  finished  in  1819.  The  Western  Fountain,  situated  at  Charles  and 
Camden  Streets,  was  supplied  by  pipes  leading  from  Clopper*s  Spring,  several 
squares  distant,  at  the  edge  of  the  basin.  The  spring  was  purchased  by  the 
city  in  1816,  and  the  fountain  or  spring-house  was  completed  some  years  later. 
Clopper,  who  had  owned  the  spring,  supplied  vessels  with  water  at  a  neighbor¬ 
ing  dock.  As  late  as  1832,  surplus  water  from  this  spring  was  led  by  under¬ 
ground  pipes  to  a  wharf  on  Light  Street.  The  Center  Fountain,  in  Marsh 
Market,  furnished  an  abundant  supply  of  water  piped  down  from  a  spring 
situated  in  the  hill,  near  the  present  Center  Street,  in  the  park  surrounding 
John  Eager  Howard’s  residence,  Belvedere.  It  was  written  (2)  of  this  spring 
in  1832 : 

“  It  enjoys  the  best  reputation  of  all  the  fountains.  As  it  springs  from  the  base  of  a 
hill  in  a  neighborhood  in  which  there  are  few  dwellings,  it  is  considered  of  less  equivocal 
origin  than  is  occasionally  imputed  to  the  other  three ;  and  inasmuch  as  the  virtues 
of  filtering  water  are  not  possessed  by  the  soil  of  Baltimore — at  least  in  the  public 
estimation — the  Center  Fountain,  which  requires  no  purification,  is  the  most  esteemed 
by  the  water  drinkers  of  this  day.” 

The  City  Fountain,  or  Spring  House,  situated  at  or  near  the  corner  of  the 
present  Calvert  and  Saratoga  streets,  was  erected  after  the  purchase  of  the 
property  by  the  city  in  1808,  about  the  time  when  Calvert  Street  was  opened 
at  this  point.  It  derived  its  water  from  several  springs,  which  had  long  been 
in  use  and  which  sprang  from  the  sides  of  the  hills  that  overhung  the  original 
course  of  Jones  Falls  at  this  point. 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


125 


That  the  authorities  were  at  an  early  date  sensible  of  the  danger  of  pollution 
of  public  and  private  springs  and  wells  is  clear  from  the  ordinances,  in  regard 
to  the  location  and  construction  of  privies,  passed  in  1817,  1820,  and  1821.  As 
these  ordinances  provided  that  privy-wells  to  be  constructed  in  the  future 
should  be  water-tight  and  that  only  such  old  privy-wells  or  vaults  as  were  on 
docks,  wharves,  or  in  made  ground,  or  which,  in  the  opinion  of  the  health 
authorities,  might  corrupt  the  Eastern  or  Western  Fountains,  were  to  be  of 
this  type,  and  as  they  especially  exempted  privies  situated  without  the  limits 
of  direct  taxation — the  “  precincts  ” — estimated  in  1816  to  include  16,000 
inhabitants,  it  is  clear  that  they  failed  to  safeguard  adequately  the  waters  of 
springs  and  wells  within  the  city.  The  enforcement  of  these  ordinances  was 
doubtless  responsible  for  diminishing,  or,  as  on  low  grounds,  for  actually 
eliminating  some  water  pollution,  but  in  general  they  did  not  cover  at  least 
the  greater  part  of  the  old  privies. 

Before  this  time  and  later  there  were  great  numbers  of  private  and  public 
wells  scattered  throughout  all  parts  of  the  city.  Beginning  in  1797,  the  city 
authorities  would  dig  a  well  and  erect  a  pump  anywhere  on  petition  of  eight 
householders  residing  in  the  vicinity  of  the  proposed  pump.  These  wells  were 
particularly  numerous  in  the  closely  built  sections  of  Felhs  Point  and  in  that 
part  of  the  city  west  of  Jones  Falls  and  near  the  basin,  in  which  places  they 
were  most  open  to  pollution  both  from  the  surface  and  through  the  soil.  In 
1798  a  superintendent  was  appointed  for  each  ward  to  see  that  the  wells  and 
pumps  were  kept  clean  and  in  good  repair.  In  1803  two  superintendents  were 
appointed  to  supervise  the  sinking  of  wells  and  the  erection  of  pumps  within 
the  city.  According  to  Wynne,  in  1849  the  pump  (well)  water  was  offensive 
to  the  taste  and  decidedly  hard,  and  it  was  seldom  used  by  those  who  could 
obtain  a  supply  from  the  water  company ;  but,  as  will  appear  later,  this  supply 
was  then  available  certainly  for  not  more  than  a  third  and  probably  not  more 
than  a  fourth  of  the  population. 

In  the  very  nature  of  things  this  intra-urban  water-supply,  drawn  from 
sources  necessarily  contaminated  with  human  excreta  deposited  in  the  ground 
in  cesspools  or  on  the  ground  in  surface  privies,  both  nearby,  became  grossly 
polluted  at  an  early  date  in  the  history  of  the  town  and  city.  Between  1790 
and  1860,  with  the  extraordinarily  rapid  growth  of  a  closely  built  city,  con¬ 
ditions  conspired  to  increase  the  degree  of  this  pollution.  Long  after  a  general 
water-supply  became  available  to  most  of  the  inhabitants,  many  held  tenaciously 
to  springs  and  wells  for  their  drinking  water.  Within  the  memory  of  those  not 
yet  of  middle  age,  many  people,  even  in  the  wealthiest  sections  of  the  city, 
preferred  to  drink  water  from  nearby  pumps,  some  of  which  enjoyed  consider¬ 
able  local  fame. 

As  early  as  1792,  the  legislature  granted  permission  to  a  fire  insurance  com¬ 
pany  to  organize  the  Baltimore  Water  Company,  with  the  privilege  of  supply¬ 
ing  water  to  private  users,  but  this  privilege  was  not  exercised.  In  February 
1799,  the  city  council  authorized  a  commission,  of  which  the  mayor  was  a 
member,  to  contract  for  a  public  water-supply  to  be  obtained  from  either 
Gwynn’s  Falls,  Jones  Falls,  or  Herring  Run  and  distributed  to  the  different 
parts  of  the  city.  This  came  to  naught,  probably  because  authority  had  not 
been  first  obtained  from  the  legislature.  These  powers  were  obtained  in  1800, 


126  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

and  in  1803  the  city  government  appointed  a  commission  to  examine  creeks 
and  streams  within  10  miles  of  the  city  and  to  select  one  for  a  copious  and 
permanent  supply  of  “  wholesome  water.” 

When  nothing  tangible  had  been  accomplished,  owing  to  delays  on  the  part 
of  the  city  government,  a  public  meeting  was  held  on  April  21,  1804,  at  which 
a  committee  of  prominent  citizens,  including  John  Eager  Howard,  was  ap¬ 
pointed,  under  the  chairmanship  of  General  Samuel  Smith,  to  organize  a 
stock  company  for  this  purpose.  Apparently  the  motive  of  the  organizers  was 
not  profit  based  in  any  degree  upon  privilege,  but  a  patriotic  desire  to  insure 
an  ample  supply  of  a  necessity  for  health  and  for  fire  protection.  The  Balti¬ 
more  Water  Company  was  formally  organized  on  May  24,  1804,  and  on  Febru¬ 
ary  14,  1806,  it  was  granted  powers  to  lay  pipes  and  to  convey  water  under 
and  along  the  streets,  lanes,  and  alleys  of  the  city. 

At  FelFs  Point,  where  the  ground  was  low  and  abounded  in  marshes,  much 
of  which  had  to  be  filled  in  and  was  therefore  particularly  unsuited  for  wells, 
and  nearby  hills,  from  which  spring-water  could  be  conveniently  drawn,  were 
lacking,  the  demand  for  an  external  water-supply  was  more  insistent  than  in 
that  part  of  the  city  lying  west  of  Jones  Falls.  In  a  small  area  there  was  a 
considerable  population,  and  here,  too,  owing  to  the  fact  that  vessels  of  deep 
draft  and  long  voyages  docked,  the  demand  for  water  for  ships  was  great  at 
FelFs  Point.  It  is  not  surprising,  then,  that  on  March  26,  1804,  the  city  gov¬ 
ernment  granted  to  John  O’Donnell,  a  member  of  the  water  commission  of 
1799,  and  others  the  rights  to  conduct  water  “  through  proper  pipes”  from 
a  “  spring  near  the  Harford  Road  ”  to  supply  themselves  and  tenants  of  houses 
fronting  on  Market  Space  and  neighboring  wharves  and  appropriated  a  piece  of 
ground  on  the  market  space  for  a  reservoir,  nor  that  in  1808,  Joseph  and  James 
Biays  sought  and  obtained  the  rights  to  convey  water  by  pipes  under  the 
streets,  lanes,  and  alleys  of  FelFs  Point.  How  far  these  projects  were  carried 
is  not  certain,  but  it  is  probable  that  they  were  merged  into  those  of  the 
Baltimore  Company. 

After  much  discussion,  Jones  Falls,  the  most  convenient  stream,  was  chosen 
as  the  source  of  supply  for  the  Baltimore  Water  Company.  A  reservoir  was 
constructed  on  the  high  ground  at  the  intersection  of  the  present  Cathedral 
and  Franklin  Streets,  a  point  well  outside  of  and  overlooking  the  young  city. 
Pumps  driven  by  a  water  wheel  and  located  near  the  present  site  of  the 
Calvert  Street  Station  on  Jones  Falls,  due  east  of  the  reservoir,  forced  water 
into  the  reservoir  from  the  common  mill-race  of  KellaPs  Dam,  which  supplied 
power  for  the  Salisbury  Mill,  situated  near  the  old  Belvedere  Bridge.  This 
mill-dam,  located  just  east  of  the  site  of  the  present  Guilford  Avenue  Bridge, 
was  well  above  all  city  habitations,  including  those  in  Old  Town,  which  marked 
the  highest  limit  of  the  built  up  section  at  that  time.  Soon  after  this  time  the 
company  erected  a  second  pumping-station  (later  with  steam  pumps  in  reserve) 
near  the  Belvedere  Bridge,  and,  in  1838,  constructed  an  additional  reservoir, 
with  a  capacity  of  3,000,000  gallons,  near  the  intersection  of  the  present  Chase 
and  Charles  Streets.  A  third  reservoir,  the  old  Mount  Vernon  Reservoir,  with 
a  capacity  of  15,000,000  gallons,  was  built  in  1846  near  the  present  site  of  the 
Pennsylvania  Railroad  Station  on  North  Charles  Street  and  was  supplied 
with  water  by  natural  flow  from  the  dam  of  the  Lanvale  Cotton  Mill,  situated 
some  little  distance  above  on  Jones  Falls. 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


127 


All  the  original  water-mains  and  service-pipes  were  made  of  wood.  The 
former  were  of  hemlock  logs  about  8  feet  long,  with  bores  of  from  to  4 
inches  in  diameter.  One  end  of  each  log  being  trimmed  to  the  shape  of  a 
spigot  and  the  other  end  being  bored  to  a  bell-shape,  the  joints  were  made  by 
driving  the  spigoted  end  of  one  log  into  the  bell-shaped  end  of  its  mate  and 
securing  them  by  a  wrought-iron  band.  The  main  valves  were  of  cast  iron 
with  tapering  spigot  ends  which  were  driven  into  the  wooden  mains.  The  valves 
were  opened  by  lifting  the  valve-plugs  with  hooks.  The  service-pipes  were  of 
cedar  logs  about  6  feet  long  and  6  inches  in  diameter,  with  bores  of  1  inch. 
They  were  connected  to  the  mains  by  means  of  tapering  ferrules  of  brass. 
These  log  mains  and  service  pipes  have  been  dug  up  in  nearly  all  the  old 
streets  near  the  water-front  in  the  Fell’s  Point  section,  as  well  as  in  the  district 
represented  by  the  original  Baltimore  Town,  to  the  west  of  Jones  Falls. 

It  is  not  improbable  that  the  water,  in  passing  through  those  wooden  pipes, 
w^as  frequently  contaminated  by  the  seepage  through  cracks  and  joints  from  the 
polluted  soil  in  which  the  pipes  were  laid.  In  the  report  of  the  sewerage 
commission  for  1910  there  is  a  photograph  of  some  wooden  water  pipes  “  about 
one  hundred  years  old,  found  in  the  sewer  trench  in  Exeter  Street,  between 
Lexington  Street  and  Necessity  Alley.”  These  logs,  evidently  belonging  to 
a  very  large  main,  were  apparently  not  connected  as  in  the  above  description, 
which  is  taken  from  Mr.  Quick,  for  there  is  no  evidence  of  bell-shaped  and 
spigot-shaped  ends.  Judging  from  the  photograph,  they  were  probably  joined 
by  metal  sleeves,  either  fitted  into  the  bore  or  sunk  into  the  peripheral  part  of 
the  logs.  In  the  nearest  log  in  the  photograph  there  is  a  large  longitudinal 
crack,  extending  from  the  lumen  to  the  surface.  It  seems  probable  that, 
with  the  varying  pressure  in  such  pipes,  there  was  not  only  considerable  leakage, 
but,  on  occasions  and  under  favorable  conditions,  seepage  of  polluted  ground- 
water  into  the  water  system.  It  is  stated  by  Wynne,  writing  in  1849,  that 
after  1820  all  the  new  mains  were  of  iron  and  the  new  service  pipes  were  of 
lead.  The  water-mains  at  this  time  varied  from  3  to  18  inches  in  diameter. 

The  new  water-supply  became  available  for  household,  fire,  and  general 
purposes  in  1808,  when  the  population  of  the  city  was  about  40,000;  but,  since 
it  was  generally  extended  only  into  such  sections  as  would  pay  interest  on  the 
expenditure,  the  water  was  used  by  a  relatively  small  part  of  the  population 
for  potable  purposes.  As  late  as  1849,  according  to  Wynne,  the  mains  were 
laid  in  only  about  one-half  the  populated  portion  of  the  city,  and  about  5,000 
houses  were  supplied  with  hydrants  with  unlimited  use  of  water.  Since  the 
population  was  about  160,000  at  this  time  and  most  of  the  houses  were  small — 
the  greater  number  being  two  stories  high  and  many  only  one — it  is  evident 
that  even  at  this  late  date  certainly  not  over  one-third  and  probably  not  over 
one-fourth  of  the  inhabitants  were  furnished  with  this  water-supply.  There 
were,  however,  some  free  hydrants  paid  for  by  the  city  for  the  use  of  the  poor. 
The  charges  for  the  use  of  water  by  private  families  were  $10  per  annum  for 
houses  over  17  feet  front,  $8  per  annum  for  houses  under  17  feet  front,  and 
$3  per  annum  extra  for  each  bath  and  water  closet.  The  daily  consumption 
of  water  (including  150  fire-plugs)  w^as  from  500,000  to  1,000,000  gallons  in 
summer  and  much  less  in  winter. 

In  the  early  days  this  water  was  subject  to  some  contamination  from  the 
privies  of  Towson,  of  the  few  settlements  about  the  mills  on  Jones  Falls  and 


128  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

its  tributaries,  and  of  the  farms  on  the  water-shed.  To  what  degree  the 
country-side  had  become  infected  from  the  city  is  unknown,  but  it  is  probable 
that  the  infection  was  not  great  before  1850.  In  1851,  according  to  T.  H. 
Buckler,  from  2,000  to  3,000  people  lived  on  this  water-shed  within  4  miles 
of  the  city.  The  water  was  muddy,  because  the  adjacent  land  was  under  cul¬ 
tivation,  and  offensive,  because  of  the  large  quantities  of  organic  matter  in  the 
shape  of  barnyard  manure  and  poudrette  put  on  the  soil. 

It  would  appear  that  the  city  government  was  not  satisfied  with  the  water- 
supply,  for  Mr.  John  Randall,  jr.,  made  an  official  report  to  the  city  authorities 
in  1836,  in  which,  after  a  survey  of  all  the  eligible  streams  in  the  neighborhood 
of  the  city,  he  recommended  the  Great  Gunpowder  Falls  as  the  best  source. 
He  estimated  that  this  would  furnish  65,000,000  gallons  of  water  every  24 
hours  in  the  dry  season.  He  proposed  that  a  dam  be  built  at  Tyson’s  Mills  on 
the  Gunpowder  River  and  another  on  Western  Run,  with  a  connecting  aqueduct 
constructed  across  the  valley  of  Beaver  Dam,  passing  to  the  limestone  ridge 
between  Cockeysville  and  a  point  near  Timonium  and  separating  the  Gunpowder 
and  the  Jones  Falls  water-sheds.  From  this  point  the  water  was  to  be  carried 
by  an  aqueduct  passing  through  this  ridge  and  thence  along  the  valley  of  J ones 
Falls  Creek  to  a  large  reservoir  near  the  city,  with  an  elevation  of  300  feet 
above  mean  tide.  The  matter  did  not  go  further  at  this  time. 

In  1849,  Wynne  described  the  Jones  Falls  water-supply  as  pure,  sweet,  and 
soft,  while  T.  H.  Buckler,  writing  in  1874  (42),  pictured  it  as  muddy  and 
offensive  to  both  taste  and  smell  at  times  in  the  summer.  Buckler,  about  this 
time,  urged  the  substitution  of  the  Gunpowder  for  the  Jones  Falls  water- 
supply. 

In  1854  the  city  acquired  the  property  of  the  Baltimore  Water  Company. 
The  supply  of  water  derived  from  the  then  existing  dams  on  Jones  Falls  being 
inadequate,  the  question  of  a  choice  of  a  new  water-supply  came  to  the  fore 
again.  After  a  sharp  discussion  of  the  relative  merits  of  Jones  Falls  and  the 
Gunpowder  River  as  sources  of  a  new  water-supply,  the  contest  was  decided  in 
favor  of  tlie  former.  By  means  of  a  dam  at  Relay  Station  on  the  Northern 
Central  Railroad,  an  impounding  reservoir  was  made  called  Lake  Roland, 
with  an  elevation  of  220  feet  above  mean  tide  and  an  available  capacity  of  400,- 
000,000  gallons.  From  this,  by  means  of  a  tunnel  4  miles  long,  water  was  led 
to  two  new  reservoirs,  one  at  Hampden,  with  a  storage  capacity  of  50,000,000 
gallons,  and  a  second,  the  present  Mount  Royal,  with  a  storage  capacity  of 
30,000,000  gallons.  The  system  was  put  into  use  in  1862.  The  consumption  of 
water  was  not  over  8,000,000  gallons  a  day,  and  the  daily  available  supply  was 
estimated  at  not  under  20,000,000  gallons. 

In  1870  the  present  Druid  Hill  Lake,  in  Druid  Hill  Park,  with  a  storage 
capacity  of  429,000,000  gallons,  was  completed.  The  west  high-service  reser¬ 
voir  in  Druid  Hill  Park,  with  an  elevation  of  320  feet  above  mean  tide, 
was  finished  4  years  later.  In  the  8  years  between  the  acquirement  of  the 
water-works  by  the  city  in  1854  and  the  coming  into  use  of  the  new  water- 
supply  in  1862,  the  contamination  of  the  water  shed  must  have  become  much 
more  serious.  During  the  Civil  War  Baltimore  was  not  only  a  great  center 
for  the  collection  and  distribution  of  Federal  troops,  but  for  large  and  numerous 
military  hospitals.  Through  the  city  passed  great  numbers  of  soldiers  going  to 
and  coming  from  the  armies  of  the  Potomac,  West  Virginia,  Kentucky,  and 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


129 


Tennessee,  and  to  the  city  were  sent  not  only  the  wounded,  but  the  sick  of 
armies  notoriously  heavily  infected  with  typhoid  fever,  diarrhoea,  dysentery, 
and  malaria.  It  is  probable  that  these  soldiers  spread  these  diseases  by  all  pos¬ 
sible  means  in  the  city  and  in  the  suburbs. 

It  became  evident  in  1872,  a  year  of  exceeding  drought  and  consequent  water 
famine,  that  the  water-supply  would  have  to  be  reinforced.  As  a  temporary 
expedient,  a  dam  was  constructed  at  Merideth’s  Ford  on  the  Gunpowder  Eiver, 
and  5,000,000  gallons  of  water  were  pumped  daily  through  a  main  over  the 
dividing  ridge  between  the  Gunpowder  and  Jones  Falls  water-sheds  into  the 
channel  of  Eoland  Eun,  a  tributary  of  Jones  Falls  above  Lake  Eoland. 

In  1875  the  city  undertook  the  following  extensive  water-works:  An  im¬ 
pounding  reservoir  on  the  Gunpowder  Eiver  at  Loch  Eaven,  with  a  dam  300 
feet  long  and  30  feet  high  and  a  storage  capacity  of  510,000,000  gallons;  a 
gate-house;  a  supply  tunnel  7  miles  long,  leading  to  a  receiving  reservoir 
(Lake  Montebello),  with  a  storage  capacity  of  500,000,000  gallons;  and  a 
conduit  a  mile  long  to  a  gate-house  at  Clifton,  with  a  40-inch  main  to  deliver 
water  to  the  general  mains.  The  new  Gunpowder  water-supply  came  into  use 
September  26,  1881. 

An  additional  storage-lake  at  Clifton  Park,  with  a  capacity  of  265,000,000 
gallons,  was  put  into  use  in  1888. 

Between  1881  and  1915,  under  ordinary  conditions,  seven-eighths  of  the 
general  water-supply  was  derived  from  the  Gunpowder  Eiver  and  one-eighth, 
from  the  old  Lake  Eoland-Jones  Falls  system.  However,  until  1885,  a  small 
area  in  the  southwestern  part  of  the  city  was  supplied  by  the  Baltimore  County 
Electric  and  Water  Company. 

In  the  20-year  period  between  1862  and  1881,  during  which  the  city  had 
enormously  augmented  and  extended  the  service  of  the  extra-urban  water- 
supply,  an  ever-increasing  proportion  of  the  population  must  have  voluntarily 
abandoned  the  internal  sources  derived  from  springs  and  wells.  It  was  not 
until  1876  that  any  serious  effort  was  made  by  the  health  authorities  to  have 
the  use  of  well  and  spring  waters  abandoned.  In  that  year,  after  a  very  fatal 
outbreak  at  Fell’s  Point  of  so-called  typho-malarial  fever  (which  was,  however, 
yellow  fever),  Health  Commissioner  Stewart  employed  Professor  William  P. 
Tonry  to  make  chemical  analyses  of  the  water  of  certain  wells  in  this  locality. 
All  of  the  wells  were  condemned  on  account  of  the  high  content  of  chlorine  and 
organic  matter.  On  the  basis  of  this  report  and  the  fact  that  the  subsoil  of 
Baltimore,  for  at  least  10  of  the  total  of  17  square  miles,  was  contaminated 
from  privies  and  cesspools,  the  commissioner  of  health  concluded  that  all 
the  wells  and  springs  within  the  city  must  of  necessity  be  polluted  or  subject 
to  pollution.  He  therefore  urged  that  they  be  closed  and  city  water  substituted. 

Professor  Tonry  examined  84  samples  of  water  from  wells  and  springs  in 
the  city  in  1879.  He  condemned  74  of  these  as  contaminated.  Many  were  in 
close  proximity  to  privies  or  to  cesspools.  Waters  from  11  wells  contained  a 
larger  percentage  of  free  ammonia  than  a  mixture  of  distilled  water  and  urine, 
one-tenth  part  of  which  was  urine.  The  next  year,  the  commissioner  of  health 
recommended  the  closing  of  all  wells  and  springs  within  the  city  limits. 

In  1885,  Dr.  Steuart,  in  his  report  as  commissioner  of  health,  gave  a  table 
showing  the  location  of  the  wells  within  the  city,  so  far  as  reported  to  the 
department.  It  was  known  that  there  were  219  abandoned  wells,  and  that  49 


130  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


dug  and  13  artesian  wells  were  still  employed.  He  estimated  that  at  least  100 
dug  wells  were  in  use.  The  majority  of  the  49  reported  were  in  the  most 
crowded  sections  of  the  city.  In  this  year,  Professor  Tonry  condemned  12  springs 
as  contaminated.  The  first  investigations  into  the  general  water-supply  were 
made  during  this  year.  Of  four  samples  of  the  Gunpowder  supply,  from  the 
gate-house  at  Loch  Eaven  and  tributary  streams,  three  were  classed  as  bad.  One 
sample  of  this  supply,  taken  at  Lake  Montebello,  was  suspicious.  All  four 
samples  of  the  Lake  Roland  supply,  taken  from  a  city  tap,  were  classed  as 
good,  but  samples  from  Druid  Hill  Lake  and  Lake  Roland  were  marked  sus¬ 
picious.  Later  in  the  year  (July)  Professor  Tonry  found  that  samples  of  tap- 
water  from  both  supplies  were  suspicious. 

With  the  annexation  of  1888,  a  large  territory,  in  some  parts  of  which  the 
most  primitive  sanitary  conditions  obtained,  was  taken  into  the  city.  In  much 
of  this  territory  the  water-supply  was  drawn  entirely  from  wells  and  springs, 
which,  according  to  the  report  of  the  commissioner  of  health,  were  “  without 
exception  polluted  to  the  foulest  degree.  ...  In  one  instance,  in  the  village 
of  Woodberry,  there  were  15  cases  of  typhoid  fever  surrounding  the  locality  of 
one  pump,  from  which  these  people  all  derived  water.” 

The  water  department  rushed  the  laying  of  water-mains  as  rapidly  as  possible 
in  the  more  densely  populated  portion  of  this  area,  but  for  many  years, 
especially  in  Hampden  and  Woodberry,  inhabited  largely  by  mill  workers, 
wells  persisted  as  the  only  or  at  least  the  main  source  of  water-supply.  In 
fact,  only  in  very  recent  years,  as  water  mains  have  been  gradually  extended, 
has  it  been  practicable  to  close  most  of  the  wells  in  this  annex.  In  the  sparcely 
settled  areas  at  the  borders  of  a  city  there  must  always  be  some  wells  allowed. 
In  Baltimore,  as  elsewhere,  authorities  have  had  difficulty  in  forcing  some 
people  to  abandon  wells  and  springs  to  which  they  were  accustomed  for  a  central 
water-supply,  recently  made  available,  until  it  could  be  conclusively  proven  that 
the  wells  were  polluted.  As  late  as  1910,  71  samples  were  examined  within  the 
year,  64.7  per  cent  of  which  were  found  to  be  polluted.  Though  it  had  long 
been  generally  known  that  both  water-sheds  were  grossly  polluted  from  human 
and  animal  sources,  it  was  not  until  1892  that  its  danger  to  public  health  was 
recognized  and  official  steps  were  taken  to  remedy  this  condition.  In  conse¬ 
quence  of  complaints  of  possible  pollution  of  the  Lake  Roland  water-shed 
from  villages  and  farm-houses,  some  inspections  were  made  by  the  health  de¬ 
partment  this  year,  and  many  glaring  nuisances  were  abated.  Routine  sanitary 
inspection  under  a  medical  officer  of  the  Lake  Roland  and  Gunpowder  water¬ 
sheds  was  instituted  in  1896,  and  in  this  and  succeeding  years  many  sources  of 
serious  pollution  were  discovered  and  some  of  the  worst  were  abated  with  the 
assistance  of  the  State  Board  of  Health.  Many  of  the  worst  sources  of  pollu¬ 
tion,  which  can  be  eliminated  only  by  building  sewerage  systems  with  disposal 
plants  for  certain  villages,  still  persist. 

With  the  establishment  of  chemical  and  bacteriological  laboratories  in  the 
health  department  in  1896  begins  the  first  systematic  study  of  the  general 
water-supply.  As  these  studies  vary  in  scope  and  completeness  from  year  to 
year,  it  is  not  possible  to  present  the  results  satisfactorily  in  tabular  form. 
While  the  tap-water  was  studied  each  year,  the  water  from  the  tributary  streams, 
the  impounding  lakes,  and  storage  reservoirs  was  not  examined  so  routinely. 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


131 


For  convenience  in  presenting  the  results  of  these  examinations,  the  term  of 
years  between  1896  and  1919  will  be  divided  into  three  periods:  1896  to  1910, 
1911  to  1915,  and  1916  to  1919. 

During  the  first  period,  it  may  be  said  in  general  that  the  chemical  and  bac¬ 
teriological  examinations  of  water  from  Jones  Falls  and  the  Gunpowder  Fiver 
and  certain  of  their  larger  tributaries  showed  a  high  and  constantly  increasing 
degree  of  pollution,  as  indicated  by  the  presence  of  organic  matter  and  high 
chlorine  content,  high  colony  counts,  and  the  frequent  presence  of  B.  coli  and 
certain  other  bacteria  commonly  present  in  the  intestines;  that  this  pollution 
was  evident  in  the  storage  reservoirs  to  a  lesser  degree ;  and  that  water  drawn 
from  taps  within  the  city,  though  often  giving  evidences  of  pollution,  showed 
a  decided  improvement  over  the  reservoir  water.  It  stands  out  clearly,  then, 
that  the  gross  contamination  of  the  water-supply  at  its  sources  was  modified 
to  a  considerable  degree  by  storage  in  the  city’s  reservoirs.  The  reports  of 
Dr.  William  Royal  Stokes,  city  bacteriologist,  show  that  between  1896  and  1910 
there  was  a  steady  increase  in  pollution  of  the  tap-water,  as  judged  by  B.  coli 
content,  from  4.5  per  cent  of  the  samples  examined  in  1896  to  57.3  per  cent 
in  1910.  Out  of  854  samples  examined  in  the  15  years,  73.3  per  cent  were 
positive  for  colon  bacilli.  Unfortunately,  however,  the  size  of  the  samples 
tested  was  not  uniform  and  varied  from  1  to  10  c.  c.  at  different  times.  The 
average  bacterial  count  per  cubic  centimeter  of  the  1,165  samples  of  tap-water 
examined  from  1896  to  1910,  inclusive,  was  703.7.  On  one  occasion,  Dr.  Stokes 
isolated  B.  typhosus  from  Towson  Run. 

These  findings  of  Dr.  Stokes  were  confirmed  by  Dr.  William  W.  Ford  (43). 
Dr.  Ford’s  studies  extended  over  the  5  years,  1906  to  1910,  inclusive,  and  dealt 
with  the  Gunpowder  supply  exclusively.  In  regard  to  the  water  drawn  from 
the  laboratory  tap,  the  colony  count  per  cubic  centimeter  was  usually  between 
500  and  600,  sometimes  as  low  as  300,  and  occasionally  after  heavy  rains  as 
high  as  1,500  or  even  2,000.  Fermentation  tubes  almost  constantly  gave  posi¬ 
tive  presumptive  tests  when  inoculated  with  1  c.  c.,  often  with  0.1  c.  c.,  and 
occasionally  with  0.01  c.  c.  samples.  On  further  study,  the  fermentation  was 
shown  to  be  due  to  five  main  types  of  bacteria  (B.  coli ,  B.  proteus  vulgaris, 
B.  cloacae,  B.  para-typhosus,  B .  fceculis  alkaligenes) ,  of  which  B.  coli  was  the 
most  constant.  Dr.  Ford  found  that  the  number  of  bacteria  per  cubic  centi¬ 
meter  in  the  Gunpowder  River  and  some  of  its  most  important  tributaries 
varied  from  2,000  to  2,500  and  that  B.  coli  was  present  in  dilutions  of  0.01  or 
even  0.001  c.  c.  He  traced  the  sources  of  contamination  in  Beaver  Dam  and 
Oregon  and  Western  Runs,  all  of  which  were  grossly  polluted. 

The  second  period,  January  23,  1911,  to  September  15,  1915,  is  characterized 
by  partial  purification  of  the  general  water-supply  by  the  addition  of  calcium 
hypochlorite  constantly  and  alum  sulphate  at  times.  The  practice  was  insti¬ 
tuted  upon  the  advice  of  Dr.  William  Royal  Stokes,  and  carried  out  by  the 
engineers  of  the  water  board.  The  chemicals  were  added  to  the  water  from 
suitably  designed  mixing  tanks  with  mechanical  control  at  the  gateways  of 
the  impounding  reservoirs  at  Lake  Roland  and  Loch  Raven.  The  parts  of 
available  chlorine  per  million  varied  at  different  times  from  0.6  to  2.25. 
The  remarkably  good  effects  of  this  treatment  are  illustrated  by  the  marked 
fall  in  the  colony  counts  and  in  the  percentage  of  B.  coli  determinations  and  in 
the  decrease  in  the  mortality  and  morbidity  rates  for  typhoid  fever. 


132  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


The  third  period  (after  September  15,  1915)  begins  with  the  completion 
of  the  new  dam  and  impounding  reservoir  at  Loch  Raven  on  the  Gunpowder 
River  and  the  extensive  filtration  plant  near  Lake  Montebello,  begun  in  1911 
under  the  advice  of  eminent  engineers.  Since  this  date  the  Lake  Roland  water- 
supply  from  Jones  Falls  has  been  abandoned,  except  for  emergencies.  It  was 
used  after  heavy  chlorinization  for  a  few  weeks  in  the  winters  of  1916  and 
1917  while  some  necessary  repairs  were  made  to  a  tunnel.  For  at  least  two  years 
after  the  new  water-supply  came  into  use,  examinations  of  tap-water,  made  in 
the  bacteriological  laboratory  of  the  health  department,  showed  B.  coli  fre¬ 
quently  in  10-c.  c.  samples  and  not  infrequently  in  1-c.  c.  and  0.1-c.  c.  samples. 
In  some  months  over  25  per  cent  of  the  10-c.  c.  samples  of  the  tap-water  were 
positive  for  B.  coli.  The  findings  were  often  at  variance  with  the  results 
obtained  in  the  bacteriological  laboratory  of  the  filtration  plant.  During  the 
last  two  years  (1918  and  1919),  the  percentage  of  positive  B.  coli  determina¬ 
tions  in  both  laboratories  was  relatively  low.  The  colony  counts  have  been 
correspondingly  low.  Intestinal  organisms  other  than  B.  coli ,  with  the  excep¬ 
tion  of  some  spore-forming  organisms,  have  similarly  become  rare.  If  low 
colony  counts  and  low  percentage  of  B.  coli  mean  pure  water,  this  water-supply 
as  treated  at  present  is  reasonably  safe. 

When  the  Baltimore  Water  Company  first  took  its  water  supply  from  Jones 
Falls,  this  water-shed  was  in  large  degree  wooded,  relatively  thinly  settled,  and 
not  extensively  cultivated.  Writing  in  1851,  Thomas  H.  Buckler  (11)  stated 
that  “  the  ordinary  current  of  Jones  Falls  is  much  smaller  now  than  it 
was  when  the  water  company  was  first  established.”  This  he  attributed  to 
the  fact  that  the  country,  on  both  sides  of  the  stream,  had,  in  the  process  of 
time,  become  more  open  and  cultivated.  Owing  to  the  substitution  of  cul¬ 
tivated  fields  for  forests,  a  smaller  proportion  of  its  water  was  filtered  through 
the  soil  and  a  larger  proportion  was  surface-water  from  cultivated  fields  and 
therefore  charged  with  organic  matter  and  soil  washings.  In  1874  (43),  he 
described  the  formerly  limpid  current  of  Jones  Falls,  furnished  from  water¬ 
sheds,  as  rendered  impure  by  manure  and  poudrette.  According  to  Buckler,  the 
Gunpowder  River  was  at  that  time  fed  by  springs  on  a  shed  which  was  for 
the  most  part  forest,  or  fields  and  meadows  cultivated  with  burnt  lime,  to 
decompose  organic  matter,  and  not  with  manure  and  poudrette.  Until  1892 
no  one  seems  to  have  taken  into  account  the  serious  pollution  of  these  water¬ 
sheds  by  human  excreta  from  the  privies  in  the  numerous  villages  and  isolated 
private  houses.  Many  of  these  village  privies  are  still  directly  over  or  on  the 
tributary  streams  of  both  water-sheds.  In  fact,  at  the  present  time,  many  of 
the  smaller  and  all  of  the  larger  tributary  streams  serve  as  sewers  of  direct 
discharge  from  villages,  smaller  settlements,  and  isolated  houses  and  institu¬ 
tions.  Human  waste  from  many  dwellings  reaches  the  streams  indirectly  by 
pipes  or  by  surface  washings  during  and  after  rains.  There  are  great  numbers 
of  horse  and  cow  stables  and  pig  sties  on  their  banks,  and  many  stable-yards 
and  paddocks  straddle  the  smaller  streams.  An  incredible  amount  of  valuable 
organic  matter  is  annually  washed  into  these  streams.  On  the  Gunpowder 
water-shed,  the  chief  source  of  pollution  with  organic  waste  and  intestinal  bac¬ 
teria  is  the  stable  rather  than  the  privy,  but  the  contamination  from  the  latter 
is  still  great,  in  spite  of  what  has  been  accomplished  of  late  years  by  the  initia¬ 
tive  of  private  individuals,  the  water  board,  and  the  State  Board  of  Health. 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


133 


Unless  some  unforseeable  revolution  occurs  in  the  methods  of  disposal  of  human 
waste,  it  is  hopeless  to  expect  that  in  any  reasonable  time  the  water  from  either 
of  these  sheds  will  be  safe  for  drinking  purposes  without  careful  treatment. 

On  account  of  the  enormous  amount  of  silt  from  surface  washings  brought 
down  from  the  cultivated  fields  by  the  heavy  rains,  the  turbidity  of  the  water 
is  often  very  great,  and  this  renders  clarification  and  purification  both  difficult 
and  expensive  at  times. 

In  recapitulation  it  may  be  said  that  until  1808  the  water-supply  was  drawn 
exclusively  from  intra-urban  sources,  many  of  which  had  been  for  years  seri¬ 
ously  polluted  with  human  and  animal  dejecta,  with  animal  and  vegetable 
waste,  slaughter-house  waste,  and  garbage,  and  that  from  1808  this  supply, 
growing  more  and  more  seriously  polluted  year  by  year,  was  very  gradually  but 
never  wholly  displaced  by  an  extra-urban  supply  from  different  sources  always 
subject  to  a  pollution,  the  grade  of  which  varied  at  different  periods  in  its 
history. 

As  late  as  1850  at  least  two-thirds  of  the  population  must  have  obtained  its 
water-supply  from  the  heavily  polluted  internal  sources.  It  was  not  until  1862 
that  the  external  water-supply  became  available  for  over  half  of  the  citizens, 
and  probably  by  this  date,  and  certainly  soon  after  it  (due  to  conditions  during 
the  Civil  War),  this  supply  had  become  heavily  polluted.  These  conditions 
were  modified  considerably  after  1872,  when  Gunpowder  water  was  to  some 
degree  mixed  with  that  of  the  Jones  Falls  water-supply,  and  particularly  after 
1881,  when  at  least  seven-eighths  of  the  water  derived  from  external  sources 
came  from  the  Gunpowder  River.  The  intra-urban  supply  was  further  cut  down 
by  the  action  of  the  health  authorities  after  1876,  but  the  annexation  of  1888 
must  have  equalized  any  gain  from  this. 

So  far  as  the  records  show,  the  purity  of  the  extra-urban  water-supply  was 
not  suspected  by  the  city  authorities  until  1892.  From  this  time  on,  evidence 
of  serious  contamination  was  clear  enough  to  the  health  authorities,  who, 
relatively  speaking,  viewed  the  situation  from  a  coigne  of  vantage;  but  the 
evidence  as  expressed  in  terms  of  typhoid-fever  incidence  and  death-rates  was 
not  sufficiently  strong  to  convince  the  mass  of  the  inhabitants  and  the  rest  of 
the  city  government  until  1910.  Had  the  typhoid  rates  been  marked  higher, 
purification  of  the  water-supply  would  have  been  undertaken  earlier. 

Why  were  not  these  rates  higher?  In  the  first  place,  the  water-sheds  were 
large,  the  cases  of  typhoid  fever  on  them  w^ere  probably  never  excessive,  and  the 
large  impounding  and  storage  reservoirs  must  have  been  very  considerable 
factors  of  safety.  As  will  be  seen  later,  there  were  other  factors  in  the  spread  of 
typhoid  infection,  which,  taken  together,  were  probably  fully  as  important  as 
water.  It  is  of  interest  that,  so  far  as  can  be  judged  by  the  published  records  of 
the  Health  Department,  typhoid  fever,  until  the  last  few  j^ears,  is  the  only 
disease  attributed  to  water. 

FOODS. 

Since  the  ordinances  of  1797  and  1805,  the  city  has  exercised  some  sort  of 
supervision  and  control  over  foods,  but,  so  far  as  can  be  ascertained  from  the 
records,  it  was  not  until  after  the  ordinance  of  1894  that  this  activity  rose 
beyond  desultory  attempts  on  the  part  of  the  market  clerks,  the  police,  and  the 
health  authorities  to  condemn  and  prevent  the  sale  of  obviously  decayed  meats, 
fish,  vegetables,  milk,  and  milk  products.  The  purpose  behind  the  laws  of 


134  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

179?  was  to  guard  against  the  importation  of  putrescent  organic  material,  wliicli 
was  considered  dangerous  in  itself,  and  to  prevent  the  shipping  from  the  port 
of  damaged  foods  which  might  injure  the  trade  reputation  of  the  city,  rather 
than  to  protect  the  inhabitants  from  foods  dangerous  to  health.  Similarly, 
the  market  law  of  1805  and  the  milk  law  of  1855  were  probably  designed  to 
protect  the  purses  of  the  poor  against  unscrupulous  dealers,  rather  than  the 
public  health  by  preventing  the  sale  of  foods  apt  to  cause  disease.  While  in  the 
reports  of  the  health  department  mention  is  frequently  found  to  the  nuisances 
in  and  about  slaughter-houses,  there  are  no  references  until  after  1890  to  the 
possibility  of  danger  to  the  public  health  from  the  meat  of  diseased  animals. 
The  State  Live  Stock  Sanitary  Board,  created  by  act  of  legislature  in  1888,  was 
intended  primarily  to  protect  the  live-stock  interests  of  the  State  through  the 
prevention  and  control  of  diseases  destructive  to  animals,  such  as  hog  cholera, 
tuberculosis,  pleuro-pneumonia  of  cattle,  trichinosis,  anthrax,  glanders,  hydro¬ 
phobia,  and  the  like,  and  in  the  administration  of  this  law  and  its  amendments 
the  activities  of  this  board  appear  to  have  exerted  until  1916  at  most  only  an 
indirect  and  secondary  influence  in  the  protection  of  the  Baltimore  population 
against  such  of  these  diseases  as  are  common  to  both  man  and  the  domestic 
animals. 

The  city  ordinances  of  1894  and  1904  in  regard  to  foods  were  directed  par¬ 
ticularly  to  the  protection  of  milk,  but  in  connection  with  milk,  they  made  it 
mandatory  for  the  commissioner  of  health  to  inspect  meat,  fish,  and  vegetables, 
to  collect  samples  of  milk  and  all  other  food  products  for  analysis  by  chemical 
and  microscopic  methods,  and  to  make  regulations  governing  them.  But  with 
a  single  chemist  and  three  inspectors  appointed  in  1894,  anything  approaching 
adequate  supervision  was  impossible.  Two  inspectors  were  assigned  to  milk 
inspection  and  one  to  meat.  It  was  not  until  1912,  when  the  laboratory  and 
inspection  forces  were  considerably  expanded,  that  other  activities  were  under¬ 
taken. 

During  its  early  history  and  until  the  development  of  the  western  packing 
industry,  practically  all  the  fresh  and  cured  meats  used  in  Baltimore  were  from 
animals  raised  in  Maryland  or  in  the  neighboring  States,  and  most  of  it  was 
slaughtered  in  or  near  the  city.  At  the  present  time  this  is  true  for  a  large  but 
diminishing  proportion  of  the  beef,  mutton,  veal,  and  pork.  There  was  no  ante- 
mortem  inspection  of  this  moiety  until  after  1888,  and  during  much  of  the  time 
since  this  date  any  such  inspection  has  been  incomplete,  to  say  the  least.  Since 
the  inauguration  of  a  meat-inspection  system  about  1900  by  the  United  States 
Government  under  the  interstate  commerce  act,  meat  sold  in  Baltimore  from 
animals  slaughtered  in  other  States  and  in  Baltimore  by  slaughterers  engaged 
in  interstate  commerce  has,  of  course,  been  submitted  to  careful  inspection. 
The  remaining  large,  but  not  exactly  known,  proportion  of  the  meats  sold  in 
Baltimore  was  submitted  to  no  post-mortem  inspection  until  1912.  As  this  in¬ 
spection  system  is  conducted  by  a  single  individual,  a  former  butcher,  and  as  the 
slaughtering  is  carried  on  simultaneously  at  a  large  number  of  widely  separated 
establishments,  it  is  evident  that  this  inspection,  as  judged  by  accepted  stand¬ 
ards,  is  hopelessly  inadequate,  both  in  regard  to  oversight  and  expert  diagnosis. 
The  single  inspector  can  not  begin  to  cover  the  field.  According  to  standards 
generally  accepted,  this  system  is  reprehensibly  inadequate,  and,  if  known, 
would  be  condemned  severely  by  a  large  element  of  the  public.  However,  after 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


1 35 


an  investigation  of  the  matter  in  1915,  the  writer  concluded  not  to  advise  the 
city  government  to  divert  money  from  directions  where  the  needs  were  so  evi¬ 
dently  much  more  marked — reform  in  the  milk-supply,  for  instance — to  estab¬ 
lish  the  traditional  meat-inspection  system.  The  evidence  that  lack  of  such  a 
system  in  Baltimore,  under  present  conditions,  does  not  appreciably  jeopardize 
the  public  health  is  very  convincing.  The  ante-mortem  inspection  of  live 
animals  is  conducted  by  the  State  authorities,  the  proportion  of  beef  and  hogs 
slaughtered  outside  of  the  United  States  Government  inspection,  both  locally 
and  elsewhere,  is  relatively  small  and  yearly  decreasing  in  proportion,  and,  in 
this  latitude,  the  common  diseases  of  calves  and  sheep  communicable  to  man 
are  comparatively  rare.  Of  greater  importance,  inquiry  disclosed  that  all  the 
cuts  and  organs  of  these  animals,  as  used  by  the  Baltimore  population,  are 
cooked  before  eating,  and,  further,  that  with  the  exception  of  a  relatively  small 
amount  of  “  country  sausage  ”  meat,  all  the  sausage  sold  is  boiled  by  the  pro¬ 
ducer  before  it  is  offered  for  sale.  From  the  administrative  side,  due  to  the  great 
number  of  small  slaughter-houses,  such  a  system  would  be  enormously  expen¬ 
sive  for  personnel  or  for  a  central  abattoir  into  which  all  the  slaughterers  could 
he  forced.  More  convincing  than  these  conditions,  however,  was  the  failure  to 
find  in  the  health  department  records  for  '20  years  previous,  deaths  attributed  to 
actinomycosis,  glanders,  anthrax,  or  trichinosis,  diseases  which,  with  the  excep¬ 
tion  of  tuberculosis,  are  the  surest  indices  of  danger  from  unguarded  butchers’ 
meat.  Under  the  law  of  1916,  the  board  of  agriculture  has  broad  powers  to 
undertake  meat  inspection,  but  it  has  not  yet  entered  this  field. 

There  are  no  accurate  figures  on  the  proportion  of  the  meats  consumed  in 
Baltimore  that  have  been  submitted  to  United  States  Government  inspection. 
There  never  has  been  any  systematic  ante-mortem  and  post-mortem  examina¬ 
tion  of  poultry  conducted  by  Baltimore  health  authorities.  Much  of  the  poultry 
sold  is  slaughtered  outside  of  the  city.  Since  1910,  health  department  inspectors 
have  exercised  a  supervision  over  poultry  sold  by  wholesale  and  retail  dealers, 
chiefly,  as  with  other  meats,  not  to  search  out  and  to  prevent  the  sale  of  dis¬ 
eased  animals,  but  of  decayed  meat.  Occasionally  an  inspector  brings  to  the 
laboratory  a  fowl  with  a  tuberculous  liver. 

In  1910,  health  department  inspectors  succeeded  to  the  supervision  for¬ 
merly  exercised  by  the  market  clerks,  the  police,  and  others  over  the  sale  of 
spoiled  fish,  crabs,  oysters,  and  other  shellfish.  Since  the  State  Board  of  Health 
and  the  oyster  commission  began  in  1915  to  supervise  the  oyster  industry  in 
the  Chesapeake  Bay  and  its  tributaries  and  practically  broke  up  the  custom 
of  “  fattening 99  oysters  at  sewer  outfalls  and  in  streams  known  to  be  heavily 
contaminated,  the  danger  of  transmission  of  typhoid  fever  and  other  water¬ 
borne  intestinal  affections  by  this  means  has  greatly  diminished.  The  great 
oyster-beds  have  probably  never  been  exposed  to  serious  contamination,  and  the 
majority  of  the  typhoid-fever  deaths  since  1880  and  of  the  cases  since  1900 
(the  date  from  which  case  reporting  has  been  sufficiently  accurate  for  com¬ 
parison)  have  fallen  in  the  hot  months  (July,  August,  September,  and  Oc¬ 
tober),  when  oysters  either  are  not  eaten  at  all  or  only  sparingly  raw. 

Until  recent  years,  practically  all  vegetables  and  much  of  the  fruit  eaten 
raw  have  come  from  neighboring  counties,  and  much  of  both  from  areas 
manured  with  night-soil  from  Baltimore,  used  either  raw  or  as  poudrette.  To 
what  degree  the  bacteria  causing  intestinal  infection  originally  deposited  in 


136  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

this  night-soil  were  killed,  overgrown,  and  smothered  by  the  putrefactive  bac¬ 
teria,  or  destroyed  by  drying  in  the  process  of  manufacturing  poudrette,  or 
killed  by  the  rays  of  the  sun  and  by  drying  on  the  surface  of  the  soil  is 
unknown,  but  it  is  improbable  that  many  survived  to  return  to  the  city  to 
spread  disease  in  connection  with  vegetables  and  fruits  eaten  raw.  It  is  not 
unlikely,  however,  that  the  dysentery  amoeba,  a  protozoan  organism,  part  of 
whose  life-history  is  characterized  by  the  formation  of  cysts,  may  survive  con¬ 
ditions  fatal  to  its  bacterial  neighbors,  and  that  amoebic  dysentery,  when  this 
disease  was  an  important  factor  in  Baltimore,  may  have  been  thus  spread. 
Perhaps  a  more  important  source  of  infection  for  the  intestinal  diseases  was 
the  water  of  polluted  wells,  springs,  and  streams  with  which  fruits  and  vege¬ 
tables  were  washed  in  the  country ;  and  the  micro-organisms  in  the  city  night- 
soil  capable  of  causing  intestinal  disease,  probably  not  infrequently,  when  by 
chance  the  conditions  of  dilution  and  aeration  were  favorable  to  their  viability, 
infected  the  sources  of  the  farmers5  wrater-supply.  It  is  quite  possible,  too, 
that  such  vegetables  as  watercress,  plucked  at  the  margin  of  branches  and 
creeks  polluted  with  privy  drainage  and  subject  to  overflow,  have  not  infre¬ 
quently  served  as  vehicles  for  the  conveyance  of  the  intestinal  diseases,  par¬ 
ticularly  typhoid  fever. 

The  milk-supply  of  Baltimore  in  the  early  days  was  derived  from  cows  kept 
in  stables  and  on  lots  in  the  city  and  from  dairies  on  farms  in  the  immediate 
suburbs.  With  the  growth  of  the  city  and  the  development  of  railroads,  the 
area  from  which  the  extra-urban  supply  was  derived  gradually  expanded  until 
it  embraced  the  counties  to  the  north,  west,  and  east,  up  to  the  area  beyond  the 
Pennsylvania  border.  The  dairies  of  the  southern  and  southwestern  territory 
of  Maryland  are  tributary  to  Washington,  and  but  little  milk  comes  to  Balti¬ 
more  from  the  tidewater  counties,  whose  direct  connection  is  by  water  only. 

The  milk  ordinances  of  1855  and  1879,  intended  to  prevent  fraud  by  adultera¬ 
tion,  accomplished  nothing.  No  machinery  and  personnel  for  their  enforce¬ 
ment  were  provided.  The  earliest  note  on  the  Baltimore  milk-supply  is  that  of 
Commissioner  Benson,  who  recorded  in  1872  that  there  were  in  the  city  1,603 
cows  in  485  stables,  with  an  average  of  344  square  feet  to  each  stable  or  104 
square  feet  to  each  cow,  which  he  regarded  as  very  satisfactory  and  as  evidence 
that  Baltimore  milk  must  be  of  the  first  quality.  The  first  real  investigation  of 
the  Baltimore  milk-supply  was  that  of  Professor  William  B.  Tonry,  made  at 
the  instance  of  the  commissioner  of  health  in  1873,  in  conducting  which  he  used 
the  approved  methods  of  that  day  to  determine  the  reaction,  the  specific  gravity, 
and  the  percentages  of  cream  by  volume,  the  total  solids,  water,  butter  fat,  milk 
sugar,  casein,  and  salts,  and  the  presence  of  blood  and  pus.  As  a  result  of  the 
examination  of  13  samples  of  milk  purchased  in  the  city,  he  concluded  that 
the  best  milk  was  that  obtained  from  “  dry-fed 55  cows  in  good  city  stables ; 
next  stood  farm  milk  brought  by  railroad,  and  last  was  rated  milk  from  badly 
stabled,  sickly,  slop-fed  cows  within  the  city.  The  best  city  milk  contained  not 
over  3.3  per  cent  butter  fat;  the  country  milk,  on  the  other  hand,  contained  over 
4  per  cent  butter  fat  and  13-J  per  cent  total  solids.  The  milk  of  the  slop-fed 
cows  was  invariably  acid,  and  it  contained  a  high  percentage  of  water  and  a 
very  low  butter-fat  content.  Professor  Tonry,  as  city  chemist,  reported  in  1894 
that  of  the  estimated  6,658,  100  gallons  sold  in  Baltimore  in  that  year,  827,450 
gallons  came  from  cows  within  the  city  limits. 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


137 


Milk  inspection  was  conducted  at  six  railroad  stations,  in  delivery  wagons 
which  supplied  households,  and  also  in  stores.  Milk  below  the  standard  set  by 
the  ordinance  (specific  gravity,  1.029;  total  solids,  12  per  cent;  butter  fat,  3 
per  cent)  was  spilled  on  the  street.  Of  288  samples  of  milk  of  which  complete 
chemical  examinations  were  made,  145  were  watered,  69  skimmed,  23  were  both 
watered  and  skimmed,  29  were  colored  artificially,  and  5  had  cream  and  3  had 
preservatives  added.  Of  68  samples  submitted  to  microscopic  examination,  only 
4  were  found  clean.  The  picture  of  Baltimore  milk  of  that  date  is  made  more 
complete  by  the  following  items  culled  from  the  report  of  Professor  Tonry  for 
the  next  year.  He  relates  that  a  city  dairyman,  after  giving  a  sponge  bath  to 
his  child  ill  with  typhoid  fever,  went  directly  to  his  milking  and  then  placed 
five  uncovered  milk  cans  of  fresh  milk  within  15  feet  of  the  sick  child.  In  the 
cellar  of  a  city  milk  and  poultry  dealer,  chickens  were  found  perched  on  the 
rims  of  open  cans  filled  with  milk.  Among  the  foreign  matter  found  in  milk 
as  received  at  the  railroad  stations,  blood,  live  frogs,  dead  mice,  leaves,  and 
decomposing  vegetables  are  mentioned.  Of  the  1,368  cows  in  the  city,  776  were 
in  the  old,  closely  built  sections,  most  of  them  in  ill-ventilated,  filthy  stables,  in 
many  of  which  were  the  family  privies  or  water  closets,  and  most  of  those  ani¬ 
mals  were  fed  brewers’  grains,  garbage,  slops,  and  decomposing  tomato  rinds. 
Over  1,000,000  gallons  of  milk  sold  this  year  'were  estimated  to  come  from  such 
cows.  Dr.  Tonry  strongly  advised  condemning  the  whole  lot.  Nearly  all  the 
milk  was  sold  from  churns  in  delivery  wagons  on  the  street  or  at  small  groceries, 
where  it  was  dipped  from  the  cans  as  needed.  Two  inspectors  examined  23,763 
lots  of  milk,  covering  132,646  gallons  out  of  the  estimated  7,500,000  gallons 
sold.  An  epidemic  of  12  cases  of  typhoid  fever  was  traced  to  milk. 

The  response  to  these  revelations  was  prompt,  and  in  1896  was  passed  the 
first  ordinance  giving  the  health  department  control  of  milk  dealers,  cows,  and 
cow  stables  within  the  city.  Of  especial  importance  were  its  provisions  requir¬ 
ing  prompt  reporting  of  the  occurrence  of  “  contagious  and  infectious  diseases  ” 
among  milch  cattle  and  in  the  households  of  dairymen  and  milk  dealers  and 
giving  the  health  department  powers  to  control  the  use  and  sale  of  milk  from 
premises  harboring  such  diseases.  The  improvement  in  the  milk-supply  was 
immediate,  for  the  report  of  the  chemist  for  this  year  showed  a  marked  fall  in 
the  percentage  of  milk  condemned  for  watering  and  skimming,  and  for  dirt. 
Of  40  samples  of  country  milk,  the  average  fat-content  was  4.13  per  cent  (high¬ 
est  4.9  per  cent  and  lowest  3.12  per  cent)  and  the  average  total  solids,  14.23 
per  cent  (highest  16.33  per  cent  and  lowest  12.23  per  cent).  The  use  of  arti¬ 
ficial  coloring  and  of  preservatives,  and  the  presence  of  blood  and  pus  were  of 
comparatively  rare  occurrence.  The  interference  with  the  watering  of  milk  with 
polluted  water  must  have  exerted  a  marked  influence  upon  the  dissemination 
of  the  micro-organisms  of  acute  intestinal  diseases  by  this  food.  The  higher 
standards  of  sanitation  for  cow-stables  set  by  the  ordinance  of  1902,  requiring 
non-absorbent  floors,  with  proper  provisions  for  drainage,  and  more  air-space 
and  range  for  cows,  and  the  appointment  of  an  inspector  of  cow-stables,  com¬ 
bined  to  make  it  relatively  unprofitable  to  keep  cows  in  closely  built-up  sections 
of  the  city.  In  consequence,  the  worst  of  the  city  cow-stables  were  eliminated. 

From  the  standpoint  of  adulteration,  the  milk-supply  showed  considerable 
improvement  by  1906,  for,  according  to  the  report  of  the  chemist,  of  the  2,209,- 
375  gallons,  or  about  14  per  cent  of  the  milk  consumed,  tested  by  the  inspectors, 


138  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


only  2,241  gallons  were  spilled,  being  either  watered,  churned,  bloody,  or  in 
filthy  condition.  The  butter-fat  percentage  of  the  1,610  samples  submitted  to 
analysis  exceeded  the  legal  requirement  by  at  least  from  0.5  to  1  per  cent. 

The  reports  of  the  bacteriological  laboratory  for  this  and  succeeding  years 
indicated  the  needs  for  supervision  and  regulation  of  a  more  drastic  type  and 
in  new  directions.  Bacteriological  examinations  of  685  samples  of  milk,  taken 
in  every  month  in  1906,  showed  in  403  colony  counts  of  over  500,000  per  cubic 
centimeter;  of  these,  89  showed  between  10,000,000  and  50,000,000,  and  10 
showed  over  50,000,000.  B.  coli  were  demonstrated  in  dilutions  of  0.001  c.  c. 
in  30  per  cent  of  the  samples  containing  under  500,000  bacteria  per  cubic 
centimeter  and  in  66  per  cent  of  those  containing  between  500,000  and  1,000,- 
000.  The  average  bacterial  counts  per  cubic  centimeter  of  milk  for  the  years 
1906  to  1908  are  given  in  table  5. 


Table  5. — Bacterial  content  of  milk. 


Month. 

Average  bacteria. 

1906. 

1907. 

1908. 

January  . 

1,000,000 

6,200,000 

1,000,000 

February  . 

2,070,000 

3,600,000 

2,200,000 

March  . 

1,900,000 

1,100,000 

5,100,000 

April  . 

930,000 

2,800,000 

1,100,000 

May  . 

5,000,000 

3,400,000 

6,000,000 

J  une  . 

4,000,000 

4,000,000 

5,000,000 

July  . 

10,000,000 

5,000,000 

6,000,000 

August  . 

23,000,000 

5,500,000 

7,400,000 

September  . 

15,000,000 

14,500,000 

3,200,000 

October  . 

10,000,000 

7,000,000 

2,100,000 

November  . 

4,100,000 

4,800,000 

1,500,000 

December  . 

1,800,000 

3,800,000 

700,000 

Average  . 

5,100,000 

5,800,000 

3,400,000 

In  1908,  Dr.  Stokes  demonstrated  by  cover-slip  counts,  microscopic  examina¬ 
tions,  cultures,  and  animal  inoculations  that  a  considerable  proportion  of  739 
samples  of  milk  so  examined  showed  pus  cells  and  streptococci  virulent  for 
rabbits.  Of  the  88  out  of  179  guinea-pigs  that  survived  one  month  after  an 
injection  of  the  sediment  of  samples  of  market  milk,  4.5  per  cent  showed 
typical  tubercles. 

The  investigations  of  the  health  department,  together  with  the  agitation  for 
purer  milk  carried  on  by  the  United  States  Department  of  Agriculture  and 
various  State  and  city  health  departments,  particularly  by  the  Woman’s  Civic 
League  and  the  Babies’  Milk  Fund,  led  to  the  comprehensive  milk  ordinance 
of  1908,  under  which  the  health  department  established  more  thorough  super¬ 
vision  of  the  market  milk  by  means  of  a  permit  system — a  system  of  extra- 
urban  dairy-farm  and  intra-urban  dairy  inspection,  and  higher  standards  of 
both  quality  and  cleanliness.  By  1913,  a  system  of  dairy-farm  inspection, 
scoring,  and  instruction  extended  to  over  1,500  dairy  farms,  and  by  cooperation 
with  the  State  Board  of  Health,  the  department  was  able  to  shut  off  the  milk 
from  farms  with  cases  of  communicable  diseases.  The  maximum  bacterial  count 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


139 


for  market  milk  was  set  at  500,000  per  cubic  centimeter.  The  conditions  under 
which  milk  was  produced  on  many  farms  was  deplorable,  but  in  a  few  years 
great  improvement  took  place.  Within  the  city  milch  cows  were  excluded  from 
the  closely  built-up  sections  and  milk  dealers  were  supervised  and  required  to 
meet  a  minimum  standard  of  cleanliness  and  care  in  handling  milk.  From  the 
reports  it  is  clear  that  the  conditions  under  which  milk  was  handled  and  sold 
at  this  time  contravened  every  canon  of  sanitary  law  and  of  common  decency. 
Only  a  small  proportion  of  the  over  8,000,000  gallons  daily  sold  was  bottled. 
The  provisions  for  washing  bottles  and  other  utensils  were  meager.  The  great 
bulk  of  the  milk  was  sold  from  “  churns  ”  or  metal  cans  with  spigots,  and  many 
of  these  cans  were  rarely  washed.  The  number  of  small  dairies  and  grocery 
stores  selling  milk  in  small  quantities  and  dipped  from  cans  numbered  hun¬ 
dreds.  There  were  no  facilities,  or  very  meager  and  dirty  ones,  for  refrigeration. 
The  bacterial  counts  of  milk  not  only  at  the  dairies,  but  at  the  stations,  remained 
high,  and  much  of  the  milk  received  in  the  warm  months  registered  high  tem¬ 
peratures.  Between  1912  and  1915  a  large  number  of  milk  dealers  adopted  pas¬ 
teurization  and  bottling  of  milk,  and  by  the  latter  year  about  60  per  cent  of  all 
the  milk  sold  was  pasteurized — much  of  it  very  incompletely.  As  a  result  of 
a  series  of  administrative  maneuvers  and  educational  campaigns,  for  which  the 
officials  concerned  are  heartily  to  be  commended,  and  the  cooperation  of  some 
of  the  more  conscientious  dealers,  the  milk-supply  and  its  control  had  greatly 
improved  by  1916.  The  goal  of  the  health  department  at  that  time  was  to  have 
all  the  milk  produced  from  healthy  cows,  handled  under  sanitary  conditions,  by 
healthy  workers,  from  farm  to  the  consumer,  properly  pasteurized  within  the 
city,  and  delivered  in  sterile  containers.  Owing  to  the  very  general  terms  of  im¬ 
portant  parts  of  the  ordinance  of  1908,  much  of  the  administrative  effort  of  the 
officials  was  of  necessity  executed  under  regulations  issued  by  the  commissioner 
of  health,  some  of  the  most  salutary  items  of  which  were  attacked  as  unreason¬ 
able  by  recalcitrant  dealers  and  in  consequence  were  held  up  indefinitely  in 
court.  This  knot  was  cut  in  1917  by  the  passage  of  an  ordinance,  which,  by 
covering  specifically  questions  immediately  in  view,  was  elastic  enough  to  grant 
power  for  the  use  of  such  alternate  procedures  as  in  the  future  might  seem  wise. 
Under  these  additional  powers,  the  health  officials  have  been  able  to  control 
producers  indirectly  and  dealers  within  the  city  directly,  so  as  not  only  to  im¬ 
prove  greatly  the  sanitary  conditions  under  which  milk  is  produced  and  sold, 
but  to  establish  grading  of  milk.  The  result  is  that  many  poorly  equipped  plants 
and  numerous  dealers  ignorant  of  milk  handling  have  been  eliminated.  Table 
6  shows  the  fall  in  the  bacterial  count  of  pasteurized  milk  since  the  law  went 
into  effect  in  November  1917. 

The  improvement  is  greater  than  appears,  however,  for  in  the  years  immedi¬ 
ately  preceding,  40  per  cent  or  over  of  the  milk  used  was  raw,  and  much  of  that 
was  served  by  the  most  illy  equipped  dealers.  Besides  the  numerous  epidemics 
of  typhoid  fever  traced  to  milk,  there  was  a  severe  epidemic  of  septic  sore 
throat  spread  by  the  milk  of  one  dairy  in  1912.  It  may  now  be  said  that  the 
public  milk-supply  of  Baltimore  has  been  safe  and  generally  within  the  legal 
standard  since  1919. 

In  the  Baltimore  market,  milk  products  are  relatively  unimportant,  with  the 
exception  of  butter,  cheese,  and  ice  cream ;  concerning  the  two  former,  because 

10 


140  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


of  the  widely  diverse  sources  of  origin  and  great  quantity  and  technical  diffi¬ 
culties  in  the  way,  no  attempt  at  supervision  for  pathogenic  micro-organisms 
has  been  attempted.  The  investigations  of  the  health  department  have  shown 
that,  until  the  last  few  years,  much,  if  not  most,  of  the  so-called  ice-cream  was 
made  of  impure,  dirty  milk  in  cellars  and  stores,  under  conditions  of  filth 
almost  unbelievable.  Under  the  inspection  system  developed  in  1912,  both  the 
sanitary  conditions  under  which  this  article  is  manufactured  and  the  standard 
of  purity  of  its  ingredients  have  been  greatly  improved.  Since  1917,  the  use 
of  only  pasteurized  milk  and  cream  in  ice-cream  has  been  permitted.  The  one 
saving  feature,  from  the  sanitary  viewpoint,  was  the  fact  that  in  making  the 
ordinary  ice-cream,  the  mixture  was  usually  cooked. 

Since  1900,  the  inspection  of  bakeries  and  confectioneries  has  been  carried 
on  under  the  health  department,  and  since  1912,  the  making  and  sale  of  bread 
and  candies  has  been  closely  supervised. 


Table  6. — Levy  average  of  numbers  of  bacteria  per  cubic  centimeter  in  samples  of 
pasteurized  milk  ( about  300  monthly)  collected  from  wagons  on  the  street. 


Month. 

Levy  average  of  numbers  of  bacteria  per  cubic  centimeter. 

1918. 

1919. 

1920. 

J  anuary  . 

282,000 

56,000 

13,000 

February  . 

475,000 

41,000 

8,300 

March  . 

450,000 

54.000 

15,000 

April  . 

650,000 

52,000 

11,000 

May  . 

1.500,000 

96,000 

22,000 

June  . 

1,200,000 

130,000 

21,000 

July  . 

1,500,000 

120,000 

34,000 

August  . 

1,700,000 

110,000 

42,000 

September  . 

840,000 

120,000 

33,000 

October  . 

350,000 

74,000 

22,000 

November  . 

115,000 

14,000 

12,000 

December  . 

71,000 

27,000 

12,000 

Besides  those  foods  above  mentioned,  analyses  have  been  made  for  several 
years  in  the  chemical  laboratory  of  canned  vegetables,  meats,  and  other  foods 
for  impurities  and  the  illegal  use  of  preservatives,  but  in  1916  work  of  this 
character  was  discontinued  as  a  routine  practice,  to  avoid  duplicating  similar 
work  conducted  by  the  State  Board  of  Health. 

II.  PREVENTION  AND  ABATEMENT  OF  NUISANCES  ON 

PRIVATE  PROPERTY. 

Since  March  20,  1801,  when  the  commissioners  of  health  were  granted  power 
to  enter  all  lots,  grounds,  and  buildings  on  which  nuisances  of  any  description 
might  exist,  down  to  the  present  day,  the  prevention  and  abatement  of  nuisances 
on  private  property  have  been  among  the  chief  activities  of  the  department,  and 
in  the  exercise  of  no  other  function  have  the  health  officials  been  brought  into 
such  intimate  relations  with  the  people.  For  many  years  this  function  and  the 
activities  in  connection  with  small-pox  (vaccination  and  isolation)  formed 
almost  the  sole  basis  of  such  contact.  In  general,  the  necessity  of  the  public 
oversight  of  nuisances  on  private  property  has  varied  directly  with  the  condition 


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141 


of  public  sanitation.  The  bulk  of  the  nuisances  has  concerned  water  and 
organic  waste.  Only  since  1886  has  cognizance  been  taken  of  nuisances  caused 
by  the  conditions  and  structure  of  buildings  as  buildings.  Having  accepted 
early  and  retained  late  the  doctrine  that  certain  diseases,  conveniently  called 
nuisance  diseases,  are  caused  by  the  putrefaction  of  dead  organic  material  and 
having  observed  that  moisture  favors  this  process,  in  the  opinion  of  both  the 
people  and  the  authorities,  it  became  a  principal  and  constant  duty  of  the 
Health  Department  to  the  full  bent  of  its  power,  means,  and  personnel,  to  keep 
these  two  things  apart.  To  this  end  the  department  has  always  had,  in  addition 
to  its  own  resources,  the  right  by  law  to  call  upon  the  police  department,  the 
legal  forces,  and  the  magistracy  of  the  city.  The  early  ordinances  concerning 
coffee  and  hides;  bark  and  the  like  on  the  wharves,  docks,  and  in  the  basin; 
sawdust  and  lumber  in  woodyards ;  offal  of  slaughter-houses,  carrion,  and  gar¬ 
bage  on  public  and  private  domains;  and  water  in  cellars  and  yards,  were  all 
directed  at  the  prevention  and  control  of  malarial,  yellow,  and  typhus  fevers, 
dysentery,  and  cholera.  Later,  diphtheria,  typhoid  fever,  and  other  acute  in¬ 
testinal  diseases  were  included  among  the  diseases  to  be  similarly  fought. 
Throughout  the  whole  history  of  the  health  department,  a  large  portion  of  its 
activities  has  centered  around  nuisances  of  these  types,  and  in  the  annual  reports 
of  the  department  much  space  is  occupied  with  their  discussion. 

STANDING  WATER. 

In  regard  to  lessening  the  amount  of  standing  water  on  private  property, 
much  was  accomplished.  By  construction,  filling,  and  drainage,  results  of  a 
more  or  less  permanent  character  could  be  obtained,  but,  because  of  the  topog¬ 
raphy  of  the  land  and  the  rapid  growth  of  the  city,  progress  was  slow  and 
design  was  always  ahead  of  accomplishment.  The  securing  of  dry  cellars  was 
a  matter  of  considerable  difficulty  in  many  parts  of  the  town,  due  to  the  abun¬ 
dance  of  springs  and  to  the  fact  that  so  much  of  the  city  was  built  upon  low- 
lying  “made  ground.”  In  many  parts  of  the  city  at  the  present  time  it  is 
necessary  to  drain  cellars  with  the  help  of  various  kinds  of  automatic  pumps  or 
cellar  drainers  worked  by  water  power.  A  very  considerable  proportion  of  the 
nuisances  reported  to  the  health  department  for  correction,  at  the  present  day, 
is  due  to  water  in  cellars,  defective  draining  of  yards  and  alleys,  broken  or 
otherwise  defective  rain-spouts,  and  leaks  in  roofs,  all  of  which  are  correctable 
on  orders  issued  by  the  health  department,  calling  for  new  construction  or 
for  repair  of  the  old. 

Shortly  after  the  discovery  of  the  relation  of  mosquitoes  to  the  spread  of 
malaria  and  yellow  fever  and  at  a  time  when  these  pests  were  common  in  many 
sections  of  the  city,  the  question  of  the  appropriation  of  money  for  the  control 
of  this  nuisance  was  agitated  in  the  city  council.  It  was  not  until  1907  that 
provision  was  made  for  the  annual  expenditure  of  $10,000  for  this  purpose 
under  the  commissioner  of  health.  In  1915,  upon  the  advice  of  Surgeon- 
General  W.  C.  Gorgas,  of  the  United  States  Army,  the  ordinance  of  that  year 
was  passed,  and  an  anti-mosquito  campaign  along  lines  familiar  to  sanitarians 
was  inaugurated  under  the  administration  of  the  department  of  street  cleaning. 
This  activity  has  been  continued  with  marked  success,  but  it  is  only  fair  to  point 
out  that  it  was  not  undertaken  until  long  after  malaria  had  practically  dis¬ 
appeared  from  the  city. 


142  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

ORGANIC  MATERIAL. 

In  the  early  days  of  the  city’s  history,  coffee  and  hides  were  the  chief  imports 
of  foreign  origin  likely  to  undergo  putrefaction.  Since  these  came  from  hot 
climates  in  wooden  ships  apt  to  leak  and  to  have  foul  bilges,  conditions  favorable 
to  their  decay  often  existed,  and  law  and  custom  demanded  their  active  super¬ 
vision  and  their  prompt  removal  from  the  city  to  special  locations  for  airing 
and  drying.  Great  quantities  of  fish,  shellfish,  vegetable  produce,  and  firewood 
were  unloaded  on  the  wharves  of  the  basin  from  small  vessels  plying  in  the 
Chesapeake,  and  the  considerable  offal  from  these  sources  created  nuisances  to 
be  supervised  by  the  health  department. 

The  sawdust  and  other  timber  waste  of  the  extensive  ship-building  and 
cooperage  plants,  all  situated  in  the  low-lying  parts  of  the  city,  near  or  on  the 
marshes  bordering  Harford  Run,  Jones  Falls,  or  the  basin,  furnished  putres- 
cible  material  in  quantities  calling  for  control  by  burning  the  waste  material 
and  by  liming  the  grounds.  So  far  did  fear  of  the  dangers  from  the  decay  of 
wood  go  that  it  was  required  that  all  lumber  and  firewood  be  so  stacked  that  air 
would  have  access  to  each  piece. 

The  health  department,  with  the  assistance  of  the  police,  has  throughout  the 
history  of  the  city  undertaken  to  enforce  ordinances  and  regulations  concerning 
the  keeping  of  yards,  areas,  private  alleys,  and  courts  clear  of  dirt,  rubbish, 
and  garbage,  but  it  was  not  until  1916  that  the  use  of  covered  metal  garbage- 
cans  was  enforced  throughout  the  city.  The  prompt  removal  from  private 
domains  of  carrion,  i.  e.,  dead  animals  other  than  those  slaughtered  for  food, 
governed  by  stringent  ordinances  since  1797,  was  exacted  of  the  owner  until  in 
recent  years. 

Though,  since  1797,  the  running  at  large  in  the  streets  of  geese,  swine,  and 
goats  has  been  forbidden  by  law,  these  and  horses,  milch  cattle,  chickens,  and 
pigeons  have  been  allowed  on  private  property  and  have  been  a  constant  source 
of  nuisances. 

There  was  no  ordinance  controlling  stables  for  cows  until  1896,  and  it  was 
only  in  1902  that  the  law  was  sufficiently  comprehensive  to  lessen  nuisances 
from  this  source  to  any  considerable  degree.  The  numerous  horse-stables, 
usually  situated  on  alleys,  courts,  and  small  lots,  and  without  manure-pits  ade¬ 
quate  in  either  size  or  structure,  were  fruitful  sources  of  nuisances  until  1913, 
when  suitable  regulations  were  issued  by  the  commissioner  of  health  and  have 
since  been  enforced  by  the  police  and  the  health  officials.  These  regulations, 
requiring  cleanliness  of  stables,  the  placing  of  manure  in  well-covered,  water¬ 
tight  pits,  treatment  with  borax  when  necessary,  and  the  emptying  of  the  pits 
and  the  removal  of  their  contents  every  seven  days  between  April  and  November, 
were  designed  primarily  to  control  the  fly  nuisance.  The  enforcement  of  these 
regulations,  together  with  reforms  in  the  care  and  removal  of  garbage  and  in 
the  cleaning  and  draining  of  streets  and  alleys,  has  resulted  in  a  very  marked 
decrease  in  the  number  of  flies,  which  in  earlier  days  swarmed  in  certain  dis¬ 
tricts  in  incredible  numbers. 

The  greatest  source  of  nuisance  upon  private  property  during  the  history  of 
the  health  department  has  been  household  drainage  containing  organic  matter — 
that  is,  household  waste-water  and  human  waste — which  was  never  well  con¬ 
trolled  until  the  completion  of  the  dual  sewage  system,  by  the  so-called  sani- 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


143 


tary  section  of  which  disposal  of  these  materials  is  now  satisfactory.  Until 
this  time,  the  household  wash-water,  consisting  of  kitchen  slops  aud  kitchen, 
laundry,  bath,  and  basin  wash-water,  passed  by  open  brick  drains  or  by  closed 
drain  pipes,  either  of  wood,  iron,  lead,  or  terra  cotta,  to  the  street  gutters.  In 
many  cases,  where  these  drains  led  from  the  front  of  the  house,  the  connections 
were  direct,  or  at  least  over  a  slight  gutter-like  depression  in  the  front  pavement, 
leading  from  the  house  pipe  to  the  gutter.  From  the  majority  of  the  houses  the 
house  drains  discharged  into  the  alley  in  the  rear,  or  alongside,  and  the  waste- 
water  followed  a  long  and  tortuous  course  over  the  rough  alleys  to  the  street 
gutters.  This  system,  at  best,  was  a  fruitful  source  of  nuisance  because  of  the 
stoppage  of  drains  and  pipes  and  the  accumulation  of  material  in  gutters 
blocked  with  paper  and  other  rubbish;  at  its  worst,  due  to  defectively  paved 
or  unpaved  and  poorly  graded  gutters  and  alleys,  larger  and  smaller  pools  of 
putrescible  fluid  collected.  Always  unsightly  and  often  disgusting,  this  material 
caused  nuisances  of  two  types :  in  cold  weather  it  froze,  resulting  in  broken 
pipes  and  drains  and  sheets  of  ice  in  yards,  alleys,  gutters,  and  street  beds,  and 
in  warm  weather  it  gave  rise  to  nauseous  odors,  drew  and  fed  flies,  and  served 
as  breeding-places  for  mosquitoes. 

Of  all  the  functions  and  activities  of  the  Baltimore  Health  Department,  none 
has  played  continuously  a  more  important  part  than  that  of  controlling  nui¬ 
sances  connected  with  human  wastes.  Owing  to  the  absence  of  a  general  system 
of  sewerage,  this  material  was,  of  necessity,  until  within  the  last  few  years,  de¬ 
posited  on  the  householder’s  lot,  either  on  the  surface,  in  the  crude  privy,  or  into 
the  ground  in  the  privy-well.  The  development  of  the  laws  relating  to  this 
subject  has  been  traced  in  the  section  on  sewerage. 

It  is  certain  that  the  privy-well,  privy-vault,  or  cesspool  was  in  existence  and 
widely  used  by  1797,  but  the  date  is  not  known  when  it  began  to  replace  the 
surface  privy.  It  is  probable  that  until  the  population  of  Baltimore  grew  rapidly 
during  the  Bevolutionary  War  and  houses  were  constructed  in  closely  built-up 
blocks  instead  of  being  separate,  as  is  the  custom  of  villages,  the  surface  privy 
was  common.  Under  those  changed  conditions  people  w7ould  have  sought  a  less 
disagreeable  method  for  the  disposal  of  human  excrement,  and  the  adoption 
of  the  cesspool,  where  the  nature  of  the  ground  would  permit  it,  was  natural. 
The  great  trouble  with  the  cesspool  system,  even  when  the  pools  or  vaults  were 
wrater-tight,  was  that,  as  with  the  privy,  the  night-soil  had  to  be  removed. 
Constant  care  and  oversight  were  necessary  to  have  them  emptied  before  they 
became  full.  With  the  introduction  of  the  wTater-closet  the  filling  and  over¬ 
flowing  of  the  cesspool  were  more  rapid  and  frequent.  Situated  either  in  the 
yards  or  under  the  cellars  of  buildings  used  for  dwellings  or  business,  the  over¬ 
flowing  cesspool  was  the  most  serious  of  all  private  nuisances. 

Since  1801  the  health  authorities  have  had  the  right  to  supervise  privies  and 
cesspools,  but  regular  inspections  were  not  required  until  1872,  when  annual 
inspection  was  required  between  June  1  and  10.  Those  which  wrere  full  or 
likely  to  be  full  before  October  1  were  declared  in  a  state  of  nuisance  and 
ordered  to  be  cleaned.  In  1886,  the  health  commissioner  wras  given  the  powrer 
to  have  privies  cleaned  and  other  nuisances  abated  at  the  expense  of  the  owners, 
agents,  or  occupiers,  when  they  had  neglected  to  do  so,  and  the  cleaning  of 
privies  was  prohibited  between  June  and  October,  except  in  case  of  necessity. 


144  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

It  was  never  the  duty  of  the  health  department  to  clean  privies  and  cesspools 
or  to  remove  night-soil,  though  it  always  supervised  this  work,  which  was  car¬ 
ried  out  by  licensed  night-soil  men.  Mr.  C.  E.  Latrobe,  C.  E.,  estimated  in 
1881  that  it  cost  the  citizens  $96,000  annually  to  have  the  contents  of  their 
cesspools  removed.  Throughout  the  history  of  the  health  department  the 
reports  of  the  commissioners  call  attention  to  the  great  number  of  nuisances  due 
to  overflowing  privies  and  cesspools  and  to  the  difficulties  in  the  disposal  of 
night-soil. 

The  final  disposition  of  the  night-soil  was  always  a  vexed  question.  Much 
of  it  was  dumped  with  garbage  on  dumps,  within  and  without  the  city  limits, 
and  it  is  probable  that  from  an  early  date  much  of  it  was  sold  directly  to  nearby 
farmers  for  use  in  the  raw  state  or  as  poudrette  (dried  night-soil  mixed  with 
charcoal  and  gypsum).  The  commissioner  of  health  in  1864  strongly  recom¬ 
mended  the  use  of  raw  night-soil  for  manure,  as  in  Europe  and  in  China.  It 
is  mentioned  in  the  report  for  1870,  as  a  great  reform,  that  three  dumps  for 
night-soil  and  street  sweepings  had  been  established  in  open  places  in  the 
suburbs,  each  under  the  charge  of  a  keeper  who  took  account  of  the  number  of 
loads  received  and  sold.  In  1880  the  method  was  changed,  and  night-soil  was 
hauled  by  contractors  to  Winans^s  Wharf,  near  the  extreme  southerly  point  of 
the  city,  or  to  Folley’s  Wharf,  at  the  southeasterly  limit,  loaded  on  barges,  and 
towed  to  some  one  of  35  localities  on  Bear  Creek,  on  Middle  River,  or  on  North 
Point  Creek,  where  the  contents  were  transferred  by  pumps  to  pits  or  tanks, 
whence  it  was  purchased  and  removed  in  tight  wagons  by  the  farmers  of  the 
several  neighborhoods  and  directly  applied  to  their  fields.  The  heavier  portion, 
which  collected  at  the  bottom  of  the  tanks,  was  applied  to  the  surface  of  fields 
owned  by  the  contractor,  where  it  was  worked  up  into  a  compost  and  sold  as  a 
fertilizer.  There  was  evidence  that  a  great  deal  of  this  material  found  its  way 
into  Bear  Creek.  At  this  time  there  were  150  different  firms  or  individuals 
licensed  as  night-soil  men.  This  method  of  disposal  was  continued  until  1917, 
when,  because  of  the  small  amount  of  night-soil,  the  business  ceased  to  be 
remunerative.  Since  this  date  the  relatively  small  amount  of  this  material  to 
be  disposed  of  has  been  dumped  into  the  sanitary  sewers  at  convenient  points. 

The  first  closets  were  directly  over  the  cesspools,  either  in  the  yard,  or  on 
back  porches,  or  in  a  room  connected  with  the  latter.  In  the  larger  houses, 
closets  of  this  type  were  on  the  porches  of  several  floors.  With  the  development 
of  the  “  water  ”  or  “  flush  ”  closet,  the  indoor  closet,  usually  in  the  bathroom, 
became  common.  The  earliest  type  of  “  water  ”  closet  in  use  in  Baltimore  was 
the  “  pan,”  consisting  of  a  bucket  or  pan,”  which,  when  a  lever  was  pulled, 
tipped  over  and  emptied  its  contents  into  the  drain  pipe  leading  to  the  cesspool 
or  sewer.  It  was  inadequately  flushed  by  about  a  gallon  of  water.  This  model 
was  in  common  use  in  1885  and  was  to  be  found  in  old  houses  as  late  as  1915. 
The  long  and  the  short  “  hopper-closets,”  improvements  over  the  pan-closet, 
were  next  very  generally  used,  especially  in  yards.  The  modern  flushing  closet 
came  into  use  very  slowly. 

A  division  of  plumbing,  with  an  inspector  of  plumbing,  was  established  in 
1883  at  the  earnest  request  of  the  commissioner  of  health,  who,  after  investi¬ 
gations  had  been  conducted  for  several  years  by  his  sanitary  inspectors,  reported 
that  in  every  household  in  which  there  had  been  a  death  from  typhoid  and  scar¬ 
let  fevers  and  diphtheria  there  was  “  defective  plumbing  ”  or  overflowing  cess- 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


145 


pools.  At  this  time  the  closet  connections  with  the  cesspools  and  private  sewers 
were  either  imperfectly  trapped  or  untrapped,  and  their  odors  often  permeated 
houses  or  whole  neighborhoods.  It  was  not  unnatural  that  a  people  bred  to  the 
belief  that  such  diseases  as  diphtheria  and  typhoid  and  typhus  fevers  are  caused 
by  poisons  in  the  air  resulting  from  putrefaction  should  embrace  and  cling  to 
the  sewer-gas  theory  of  their  causation. 

Judging  from  the  reports  of  the  health  department,  the  sewer-gas  theory, 
which  was  responsible  for  the  establishment  of  plumbing  inspection,  dominated 
the  department  from  1875  until  1895.  It  doubtless  served  a  good  purpose  in 
drawing  attention  to  the  dangers  and  inconveniences  of  the  cesspool  and  to  the 
necessity  for  tight  plumbing.  It  had  the  deplorable  consequence  of  elevating 
the  scientifically  uneducated  plumber  to  a  position  of  authority  in  hygiene. 
This  ascendency  of  plumbing  is  not  to  be  blamed  upon  the  plumber,  who  did 
not  invent  the  doctrine,  which,  with  the  mechanical  inventions  connected  with 
his  trade,  stimulated  the  demand  for  his  useful  work.  The  “  defective  plumb¬ 
ing,”  to  which  so  much  disease  was  thought  to  be  traced,  was  defective,  as  is 
shown  by  the  reports  of  Mr.  Lee,  the  first  plumbing  inspector,  not  only  in  being 
untrapped  or  improperly  trapped  and  vented,  but  in  structure  and  in  location 
as  well.  The  sewer-gas  theory  of  disease,  imported  from  England  and  adopted 
without  reservations  in  the  Baltimore  health  department,  though  like  so  many 
theories  in  medicine  quite  without  basis  in  fact,  was  made  to  serve  the  very 
useful  purpose  of  greatly  improving  plumbing.  Under  the  regulations  of  the 
commissioner  of  health  in  1898,  based  upon  the  plumbing  ordinance  of  1883 
and  the  system  of  inspection  carried  out,  the  public  was  gradually  forced  to 
install  more  and  better  plumbing  and  was  protected  against  fraud  in  its  installa¬ 
tion.  This  system  was  of  particular  help  to  tenants,  who,  on  appeal  to  the 
health  department,  could  have  long-standing  nuisances  abated.  The  additional 
provisions  of  the  building  code  of  1908  and  the  power  given  to  the  department 
by  the  sewerage  act  to  force  house  connections  with  the  sanitary  sewers;  the 
manner  in  which  these  have  been  administered  by  the  department,  and  finally, 
the  development  of  the  modern  toilet,  have  resulted  in  a  complete  revolution  of 
the  privy  and  closet  nuisances.  The  supervision  of  the  house  connections  and 
construction  of  the  plumbing  systems  of  over  90,000  buildings  between  1912 
and  1918  was  a  considerable  administrative  feat.  There  remain,  however,  some 
25,000  houses  still  dependent  upon  the  cesspool,  and  in  connection  with  a  con¬ 
siderable  number  of  old  houses  in  the  older,  crowded  parts  of  the  city,  there 
are  yard  toilets  with  “  hopper  ”  closets,  many  of  which  are  imperfectly  flushed 
and  are  frequently  out  of  order. 

Some  idea  of  the  activities  of  the  health  department  in  the  control  of  nui¬ 
sances  on  private  property  may  be  obtained  from  the  following  summary  of  the 
report  for  1880 :  The  total  number  of  nuisances  examined  by  sanitary  inspec¬ 
tors  was  4,292.  Some  of  the  principal  items  were:  Alleys  graded,  paved,  or 
repaired,  320 ;  premises  cleaned  and  disinfected,  246 ;  cellars  cleaned  and  con¬ 
nected  with  sewers,  803;  privies  reconstructed  and  repaired,  862;  vacant  lots 
drained  or  filled  up,  159;  drain  pipes  constructed  and  repaired,  158;  yards 
cleaned,  drained,  paved,  and  repaired,  228 ;  slaughter-houses  and  packing  houses 
inspected,  33.  In  addition,  notices  and  orders  to  remedy  unsanitary  conditions 
were  issued  as  follows :  Notices  issued  to  clean  privies,  17,445 ;  to  repair  yards, 
530 ;  to  clean  and  bail  out  cellars,  560 ;  to  grade  and  pave  alleys,  4,863 ;  to  drain 


146  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

and  fill  up  lots,  287;  to  clean  and  repair  water-closets,  520;  to  clean,  drain, 
and  repair  premises,  380 ;  to  clean  and  properly  construct  manure  pits,  140 ; 
to  clean  grass  and  weeds  from  lots  and  gutters,  560;  a  total  of  25,285.  There 
were  18,887  permits  issued  to  open  sinks. 

In  contrast  to  the  above,  73  fatal  cases  of  infectious  diseases  were  inquired 
into. 

In  1890  it  was  reported  that  the  sanitary  inspectors  had  examined  and  had 
abated  34,138  nuisances.  There  were  issued  14,345  notices  and  43,989  permits 
to  clean  privies,  and  10,409,800  gallons  of  night-soil  were  removed  from  the 
city  by  contractors. 

The  reports  of  succeeding  years,  until  1918,  when  house  connections  with 
the  sewerage  system  were  completed  and  half  the  alleys  were  properly  paved, 
show  corresponding  increase  in  nuisance  supervision  and  control  of  these  types. 

MANUFACTORIES. 

It  will  be  noted  that  section  6  of  Ordinance  15  of  1797  and  the  provisions 
regarding  manufactories  inimical  to  public  health  made  in  succeeding  ordi¬ 
nances  were  directed  at  the  prevention  of  offensive  odors  and  the  accumulation 
of  organic  material  on  the  property  of  manufacturers  or  its  discharge  upon 
streets  and  alleys  or  upon  the  properties  of  others,  and  they  in  no  way  prescribe 
safeguards  for  workers  in  connection  either  with  the  structure,  lighting,  and 
ventilation  of  shops  and  factories,  or  with  personal  contact  with  micro-organ¬ 
isms,  chemical  poisons,  or  irritating  particles.  Those  omissions  are  doubtless 
due  in  large  part  to  the  fact  that  industries  of  these  types  have  not  been  numer¬ 
ous  until  recently  in  Baltimore.  All  the  child-labor  and  factory  laws  are  general 
State  laws  passed  since  1884  and  are  in  large  degree  executed  by  State  officials. 

The  ordinance  of  1871,  which  provided  that  no  slaughter  or  hide  houses 
should  be  erected  within  the  city,  has  not  in  any  marked  degree  decreased  the 
number  of  such  places  within  the  city;  for,  with  the  annexation  of  1888,  a 
territory  containing  nearly  all  the  slaughter-houses  near  the  old  city  came 
within  the  corporation.  Most  of  these  were  small  private  slaughter-houses  for 
sheep,  calves,  and  cattle,  situated  in  the  rear  of  the  homes  of  their  owners,  who 
are  for  the  most  part  cleanly  and  thrifty  market  butchers,  selling  meats  of  their 
own  killing.  The  existence  of  most  of  these  small  slaughter-houses  is  unknown 
to  the  casual  passer-by,  and  they  are  but  rarely  the  subject  of  complaint  on 
the  part  of  neighbors.  Frequent  subject  of  complaint,  however,  are  the  prem¬ 
ises  of  poultry  slaughterers  in  certain  sections  of  the  city.  There  are  a  few 
large  slaughter-houses  for  hogs,  established  many  years  ago,  in  the  closely 
built-up  sections  of  the  city,  convenient  to  the  railroad  tracks,  but  these  are 
rarely,  if  ever,  at  the  present  day  at  least,  the  source  of  nuisance.  At  the 
northwest  border  of  the  city,  without  the  city  limits  before  1919,  are  the  slaugh¬ 
ter-houses  of  the  large  packers  and  the  stockyards  and  Union  Abattoir. 

HABITATIONS. 

The  laws  applying  to  habitations  passed  between  1871  and  1908,  in  so  far  as 
they  relate  to  structure  outside  of  plumbing,  are  under  the  administration  of 
the  inspector  of  buildings,  and  in  so  far  as  they  concern  cleanliness  and  manner 
of  keep,  are  enforced  by  the  health  officials. 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


147 


With  the  exception  of  those  provisions  that  deal  with  safety  where  dependent 
upon  strength  and  mode  of  structure,  the  main  object  of  the  ordinances  of  1884 
and  1908  was  to  set  a  minimum  standard  of  light  and  air  ventilation  compatible 
with  health,  to  secure  against  dampness,  and  to  provide  adequate  water  and 
toilet  facilities. 

The  ordinance  of  1884  was  passed  opportunely,  for  about  that  date  many  old 
houses  in  the  lower  parts  of  the  city,  being  vacated  by  their  former  owners  or 
tenants,  were  being  transformed  into  boarding-houses  or  into  two  and  three 
family  dwellings.  In  the  larger  of  these  there  was  the  temptation  to  divide  the 
very  large  rooms  into  two  or  more  rooms,  one  or  two  of  which  would  be  entirely 
devoid  of  daylight.  This  law  also  put  an  end  to  building  houses  with  a  window¬ 
less  central  room  on  each  floor. 

In  1900  there  was  established  in  the  health  department  a  division  of  tene¬ 
ment-house  inspection,  to  which  were  referred  not  only  the  general  oversight 
and  supervision  of  tenements,  and  of  lodging  and  boarding  houses,  but  all 
questions  relating  to  nuisances  therein.  To  this  end,  dwellings  of  these  sorts 
were  placed  under  a  system  of  repeated  systematic  inspection  designed,  on  the 
one  hand,  to  force  the  landlords  to  make  necessary  repairs  and  renewals — white¬ 
washing,  painting,  and  the  like — and,  on  the  other  hand,  to  require  the  tenants 
to  observe  the  rules  of  cleanliness. 

The  ordinance  of  1908  was  intended  particularly  to  control  the  modern  tene¬ 
ment  and  apartment  house. 

III.  MEASURES  OF  RESTRICTION,  INOCULATION,  AND  DISIN¬ 
FECTION  DIRECTED  AGAINST  THE  CONTAGIOUS  DISEASES. 

Under  this  heading  it  is  proposed  to  give  a  general  account  of  the  attitude  of 
the  health  officials  toward  the  control  of  the  spread  of  febrile  diseases,  especi¬ 
ally  those  regarded  as  contagious,  by  administrative  measures  other  than  the 
control  of  nuisances  and  the  order  in  which  their  control  was  attempted.  Con¬ 
sideration  of  the  methods  used  in  seeking  to  control  particular  diseases  and 
groups  of  diseases  is  reserved  for  later  chapters.  It  is  to  be  borne  in  mind  that 
the  official  attitude  in  regard  to  a  given  disease  varied  at  different  times.  For 
this  there  were  many  reasons,  one  of  the  most  important  of  which  being  the 
changes  in  the  knowledge  or  belief  in  regard  to  its  causation  and  mode  of 
spread.  Another  reason  was  the  idea  entertained  of  its  relative  importance 
at  any  particular  time.  A  third  reason  was  lack  of  organization  and  of  means 
at  all  times  to  pursue  ideas  to  their  ultimate  conclusions  and  thus  to  do  thorough 
work.  From  the  health  reports  and  from  contemporary  literature,  both  medical 
and  lay,  and  from  administrative  experience,  the  indelible  impression  is  gotten 
that,  throughout  its  history,  the  Baltimore  health  department  has  followed  a 
vacillating  course,  dependent  in  great  degree,  at  times  certainly,  on  lack  of 
means  and  public  support  and  often  on  absence  of  intelligent  direction.  For 
these  reasons  its  course  has  been  one  of  expectant  opportunism,  and  it  has 
rarely  met  facts  squarely  face  to  face. 

In  certain  respects,  its  attitude  has  been  consistent;  for  instance,  in  holding 
that  malaria  and  yellow  fever  are  not  contagious,  and  are  due  to  conditions  asso¬ 
ciated  with  standing  water  and  decaying  vegetable  material;  that  whooping- 
cough,  measles,  and  small-pox  are  caused  each  by  a  specific  morbific  agent  spread 
from  the  sick  to  the  well  by  personal  contact  or  by  contact  wTith  materials  inti- 


148  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

mately  associated  with  the  sick  ;  and  that  small-pox  may  be  prevented  by  vac¬ 
cination.  Yet  the  efforts  put  forth  were  never  sufficiently  adequate  to  test  these 
doctrines.  Certain  diseases,  such  as  diphtheria  and  typhus  fever,  were  tossed 
from  one  category  to  another.  Long  years  elapsed  after  it  had  been  shown  that 
cholera  and  typhoid  fever  are  commonly  spread  by  water  and  after  it  had  been 
proven  that  these  diseases  and  diphtheria  and  scarlet  fever  are  often  carried 
by  milk,  before  such  knowledge  was  reflected  in  the  conceptions  and  activities 
of  the  health  department. 

That  officials  may  exercise  properly  their  function  of  attempting  to  control 
the  occurrence  or  spread  of  diseases,  it  is  necessary  in  the  first  place  that  they 
be  informed  promptly  of  the  name  and  address  of  each  case.  For  the  exertion 
of  effective  control,  it  has  long  been  held  that  they  must  have  ample  power  to 
isolate  the  sick  and  those  in  contact  with  them,  to  disinfect  and  destroy  clothes, 
bedding,  furniture,  and  even  houses.  In  1801,  physicians  were  “  invited  ”  by 
ordinance  to  report  “  contagious  diseases,”  and  the  commissioners  of  health 
were  empowered  to  remove  persons  ill  with  such  diseases  to  a  hospital  or  other 
place  and  to  cut  off  communication  with  the  “  affected  house.”  When  such  a 
disease  threatened  to  become  general,  they  were  authorized  to  advise  the  inhabi¬ 
tants  to  remove  to  quarters  provided  for  the  purpose.  From  contemporary  medi¬ 
cal  literature,  it  is  certain  that  small-pox,  typhus  fever,  and  yellow  fever,  when 
in  epidemic  form,  were  reported  under  the  terms  of  this  invitation,  and  that 
many  individuals  ill  with  these  diseases  were  hospitalized;  that  on  more  than 
one  occasion,  on  account  of  yellow  fever,  the  inhabitants  of  Fell’s  Point  and 
other  infected  districts  followed  the  official  advice  to  flee,  and  that  many  were 
supported  in  camps  at  the  city’s  expense. 

The  ordinance  of  February  10,  1820,  in  which  the  health  laws  were  revised 
in  conformity  with  the  advice  of  the  local  medical  society,  contained  two  sig¬ 
nificant  new  features — one  requiring  physicians  to  report  cases  of  malignant, 
pestilential,  or  contagious  diseases,  and  the  other  requiring  keepers  of  taverns 
and  lodging  houses  to  report  cases  of  illness  occurring  between  March  and 
November  among  seafarers  or  other  sojourners  in  their  houses.  This  ordinance 
was  reenacted  19  days  later,  eliminating  the  section  which  required  the  report¬ 
ing  by  physicians.  This  step  was  probably  taken  at  the  behest  of  certain  promi¬ 
nent  physicians  at  Fell’s  Point  who  had  become  disgruntled  the  previous  year 
because,  wrhile  they,  themselves,  had  loyally  reported  cases  of  yellow  fever, 
physicians  in  other  parts  of  the  city,  so  they  claimed,  had  neglected  or  refused 
to  do  so.  The  health  authorities  had  to  remain  content  with  voluntary  reporting. 
The  provision  requiring  the  reporting  of  cases  of  illness  in  taverns  and  lodging, 
and  boarding  houses  has  been  retained  in  one  form  or  another  in  succeeding 
ordinances. 

The  law  of  1821,  which  empowered  the  commissioners  of  health  to  fence  off 
and  surround  by  sentinels  any  district  in  which  yellow  fever  was  “  confirmed  and 
beyond  control,”  wras  designed  rather  to  keep  people  out  of  such  districts  than 
to  prevent  the  exit  of  those  living  therein,  because  it  had  been  decided  in  1819 
for  all  time  in  Baltimore  that  this  disease  is  not  contagious.  It  had  been  ob¬ 
served,  however,  that  it  was  dangerous  to  allow  persons  to  expose  themselves 
to  the  air  of  the  districts  in  which  yellow  fever  cases  have  originated.  It  was 
the  locality  and  not  the  sick  that  was  considered  dangerous.  This  provision  was 
reenacted  in  the  various  revised  ordinances  and  appears  in  the  code  of  1869. 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


149 


When  cholera  first  appeared  in  1832,  it  was  officially  declared  to  be  non- 
contagious,  and  the  dispensaries  and  emergency  hospitals  that  were  established 
were  designed  avowedly  for  the  early  treatment  of  the  poor  and  for  the  better 
care  of  the  dangerously  ill  rather  than  for  isolation.  Similarly  in  1866,  cases 
of  cholera  were  reported,  and  though  only  one  case  (the  whole  number  is  not 
recorded)  was  traced  to  contact  with  a  previous  case,  care  was  taken  to  remove 
and  to  destroy  everything  used  by  those  affected  with  the  disease  and  to  dis¬ 
infect  and  to  bury  the  discharges  of  the  sick,  and  many  were  removed  to  a 
hospital. 

There  is  evidence  that  in  the  early  years,  isolation,  hospitalization,  and  dis¬ 
infection  were  practiced  in  the  control  of  typhus  fever,  and  after  1840,  many 
cases  were  sent  from  the  city  to  the  pest-house  at  the  Marine  Hospital.  In 
1866,  the  commissioner  of  health  reported  that  a  small  epidemic  of  typhus  fever 
was  controlled  by  sending  the  sick  to  the  hospital.  However,  in  1851,  T.  H. 
Buckler  sharply  criticized  the  authorities  for  sending  typhus  fever  patients  to 
the  general  wards  of  the  almshouse  infirmary. 

Small-pox,  the  most  dreaded  of  all  the  epidemic  diseases  in  Baltimore,  as 
the  reports  of  the  health  department  show,  was  always  reported  (though  the 
number  of  cases  is  unfortunately  not  recorded  for  all  the  years)  and  was  con¬ 
sistently  fought  by  vaccination,  by  hospitalization  of  the  sick  and  isolation  of 
the  exposed,  and  by  fumigation  or  destruction  of  personal  effects.  In  1824,  four 
emergency  vaccinators  were  appointed,  and  since  1826,  the  position  of  vaccine 
physician  has  been  permanent.  Vaccination  first  instituted  for  the  poor  was 
enforced  with  vigor  in  times  of  epidemics.  The  section  of  the  ordinance  of 
1834,  in  which  physicians  were  requested  to  report  cases  of  small-pox  within 
24  hours,  under  threat  of  having  the  names  of  those  who  neglected  or  refused 
to  do  so  published,  passed  at  the  beginning  of  an  epidemic,  was  modified  in  the 
revised  health  ordinance  of  1838  with  omission  of  the  threat.  Small-pox  was  put 
on  a  level  with  other  diseases  in  the  code  of  1869,  in  which  even  the  request  to 
report  was  eliminated. 

There  is  no  allusion  in  the  health  department  reports  to  efforts  at  the  control 
of  diphtheria,  scarlet  fever,  measles,  whooping-cough,  and  typhoid  fever  by 
isolation,  hospitalization,  or  otherwise,  until  late  in  the  nineteenth  century. 
The  prevalence  of  scarlet  fever  and  measles,  both  in  fatal  form,  is  often  men¬ 
tioned,  and  as  early  as  1838  the  consulting  physician  gave  it  as  his  opinion 
that  “  scarlet  fever  and  measles  occur  under  no  fixed  laws  and  both  seem  in¬ 
clined  to  abide  with  us.r  Diphtheria,  scarlet  fever,  and  typhoid  fever,  all 
widely  prevalent  in  1875  and  for  a  number  of  years  thereafter,  were  attributed 
to  sewer  gas.  That  diphtheria  and  typhoid  should  be  considered  foul-air  or 
nuisance  diseases  at  this  time  is  not  strange,  but  that  scarlet  fever,  a  typical 
exanthematous  disease,  considered  for  hundreds  of  years  a  specific  contactive 
disease,  should  have  been  included  in  this  group,  is  surprising. 

None  of  the  diseases  just  mentioned  were  included,  so  far  as  the  reports  of 
the  health  department  show,  among  the  reportable  diseases  until  1882,  when  bv 
ordinance  diphtheria  and  scarlet  fever,  together  with  small-pox,  varioloid, 
cholera,  and  yellow  fever  were  specifically  named  as  diseases  to  be  reported 
within  24  hours  by  physicians,  and  keepers  of  hotels  and  boarding  and  lodging 
houses,  by  agents  and  owners  of  tenement  houses  and  private  houses,  and  by 
the  managers  of  institutions.  The  list  was  amplified  by  ordinance  to  include 


150  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

whooping-cough,  mumps,  and  membranous  croup  in  1890,  but  it  was  not  until 
1895  that  typhoid  fever  was  added.  Typhus  fever  has  never  been  made  report- 
able  in  Baltimore  by  ordinance.  Though  between  1870  and  1890  the  commis¬ 
sioners  of  health  recorded  the  sending  of  inspectors  to  visit  the  houses  of  indi¬ 
viduals  dead  of  diphtheria,  or  scarlet  or  typhoid  fever,  certain  it  is  that  so  far 
as  management  of  persons  is  concerned,  nothing  was  attempted  during  these 
years  for  the  control  of  febrile  diseases  except  small-pox.  During  this  period, 
scarlet  fever,  measles,  diphtheria,  whooping-cough,  and  typhoid  fever  were  not 
only  very  prevalent  but  very  fatal,  as  attested  by  comments  of  the  commis¬ 
sioners.  The  department  seems  to  have  exhausted  its  energies  over  small-pox, 
typhus  fever,  and  nuisances.  It  was  not  until  1890  that  communicable  diseases 
were  reported  in  considerable  numbers.  In  that  year,  2,593  cases  were  men¬ 
tioned  as  visited  by  sanitary  inspectors. 

The  commissioner  of  health  at  this  time,  Dr.  George  F.  Rohe,  the  first  who 
had  a  first-hand  acquaintance  with  pathological  anatomy  and  parasitology, 
revived  the  case-reporting  and  advised  disinfection  and  fumigation  of  rooms 
and  houses  after  death  or  recovery  from  contactive  diseases  and  recommended 
systematic  hospitalization  of  cases  of  diphtheria  and  scarlet  fever.  Dr.  Rohe, 
finding  that  a  large  proportion  of  the  children  in  the  public  schools,  though 
possessing  physicians’  certificates,  had  never  been  successfully  vaccinated, 
excluded  the  unvaccinated  and  thus  laid  the  foundation  for  systematic  require¬ 
ment  of  vaccination  of  all  school  children  as  a  condition  precedent  to  admission 
into  school  in  Baltimore. 

In  1892,  the  era  of  active  and  concerted  attempt  to  restrict  contactive  diseases 
other  than  small-pox  and  typhus  fever  may  be  said  to  have  begun.  The  number 
of  vaccine  physicians,  who  acted  also  as  health  wardens  and  to  whom  fell  the 
duty  of  establishing  such  isolation  and  quarantine  in  households  as  was  at¬ 
tempted,  was  doubled,  one  being  allocated  to  each  of  the  city  wards,  and  the 
number  of  sanitary  inspectors  was  increased  to  11.  The  sewer-gas  doctrine  was 
dropped,  and  though  attention  to  nuisances  absorbed  to  a  very  large  degree  the 
activities  of  the  department,  there  are  indications  of  a  more  critical  considera¬ 
tion  of  the  natural  history  of  the  febrile  diseases,  resulting  in  a  recognition  that 
certain  of  them  may  be  spread  in  a  variety  of  ways.  As  has  been  shown  in  an¬ 
other  chapter,  this  change  was  to  a  very  great  degree  due  to  new  influences  that 
had  arisen  in  the  medical  profession  of  the  city.  Reports  of  7,475  cases  of 
“  infectious  diseases  ”  were  received  this  year,  many  children  from  “  infected 
houses  ”  were  detected  in  schools,  disinfection  and  fumigation  of  houses  are  said 
to  have  been  carefully  done,  and  12,690  articles  of  clothing  and  bedding  were 
disinfected. 

By  1894,  the  commissioner  of  health  had  demanded  a  bacteriological  labora¬ 
tory  for  the  diphtheria-culture  test,  provision  to  obtain  diphtheria  antitoxin 
for  free  distribution,  and  the  establishment  of  a  special  hospital  for  infectious 
diseases.  He  was  granted  a  chemist  and  three  inspectors  for  the  control  of 
food,  and  efforts  to  improve  and  protect  the  milk-supply  were  pushed. 

The  report  of  the  commissioner  of  health  for  1895  is  remarkable  in  that  it 
gives  the  number  of  cases  of  each  communicable  disease  reported,  contains  an 
intelligent  discussion  of  the  causation  of  typhoid  fever,  with  an  account  of  a 
milk  outbreak  of  this  disease,  and  recognizes  that  the  causative  agents  of  certain 
diseases  may  be  spread  in  several  ways. 


rUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


151 


The  year  1896  was  another  turning-point  in  the  attitude  of  the  department 
toward  communicable  diseases.  It  is  not  going  too  far  to  state  that  up  until 
this  time  everything,  and  indeed  much  more  that  the  department  had  under¬ 
taken  and  accomplished  for  the  control  of  disease  (vaccination  against  small¬ 
pox  excepted),  could  have  been  done  just  as  effectively  under  the  influence  of 
the  ideas  and  knowledge  of  a  hundred  years  before.  While  its  previous  efforts 
doubtless  had  some  considerable  influence  in  restricting  some  diseases,  care¬ 
ful  examination  of  all  the  recorded  facts  fails  to  elicit  convincing  evidence 
that,  so  far  as  those  diseases  believed  to  be  entirely  or  even  mainly  spread  by 
contact  are  concerned,  the  Baltimore  health  department  had  ever  applied 
Mead’s  recommendations  systematically  and  thoroughly  to  the  control  of  even 
one  of  them,  or  that  any  one  of  these  diseases,  even  small-pox,  to  which  it  was 
particularly  attempted  to  apply  these  principles,  and  even  with  the  assistance 
of  vaccination,  was  controlled  when  in  epidemic  form  in  any  appreciable  degree. 
As  is  clearly  shown  from  the  statements  of  the  commissioner  in  this  year,  no 
consistent  attempt  had  been  previously  made  to  carry  out  isolation,  hospitaliza¬ 
tion,  and  disinfection  in  connection  with  the  control  of  these  diseases  under 
legal  authority  possessed,  since  1801. 

From  1896  begins  in  the  health  department  a  more  serious  effort  to  apply 
consistently  old  knowledge  and  theories,  with  modifications  and  amplifications, 
under  the  stimulus  of  the  rapidly  accumulating  knowledge  of  modern  chemistry, 
pathology,  and  micro-parasitology.  The  commissioner  of  health  pointed  out 
that  efforts  to  restrict  infectious  diseases  in  past  years  had  not  had  the  desired 
effect,  and  attributed  this  failure  to  neglect  by  physicians  to  report  cases ;  lack 
of  sufficient  funds  and  appliances ;  the  superficial  and  inadequate  character  of 
the  methods  of  disinfection  employed;  and  the  absence  of  a  properly  trained 
corps  of  disinfectors,  of  a  steam  disinfecting  plant,  of  sufficient  hospital  facili¬ 
ties,  and  of  adequate  supervision  of  the  infected.  Patients  were  discharged  from 
isolation  and  quarantine  under  no  fixed  rules  and  on  the  certificate  of  the 
attending  physician  that  in  his  opinion  danger  of  transmitting  the  disease  had 
passed.  In  addition  to  remedies  for  these  delinquencies,  he  suggested  a  system 
of  school  inspection  and  the  inauguration  of  measures  to  prevent  pulmonary  tu¬ 
berculosis.  This  year  was  further  distinguished  by  the  establishment  of  labora¬ 
tories  of  chemistry  and  bacteriology,  at  the  heads  of  which  were  well-trained 
men.  In  the  latter,  the  advantage  of  laboratory  diagnostic  methods  for  diph¬ 
theria,  typhoid  fever,  malaria,  and  tuberculosis  were  at  once  offered,  and  investi¬ 
gations  of  water  and  milk  were  undertaken. 

There  were  developed  in  the  department,  during  the  next  few  years,  the 
restrictive  procedures  including  isolation  and  household  quarantine,  placarding, 
supervision  by  health  wardens,  discharge  certificates,  culture  tests,  formaldehyde 
disinfection  of  rooms,  steam  sterilization  of  clothes  and  bedding,  the  develop¬ 
ment  of  methods  to  prevent  the  spread  of  diseases  through  milk  and  other  foods, 
and  the  like,  which  in  the  main  accord  with  the  standard  practice  in  English 
and  American  municipalities.  It  is  remarkable  that  the  placarding  of  houses 
harboring  cases  of  communicable  diseases,  with  the  exception  of  small-pox,  does 
not  seem  to  have  been  practised  by  the  Baltimore  health  department,  until  it 
was  introduced  in  1898  for  diphtheria  by  Commissioner  C.  Hampson  Jones. 

Sydenham  Hospital,  accommodating  40  cases  of  diphtheria  and  scarlet  fever, 
was  opened  in  1909,  and  its  capacity  was  increased  to  60  beds  in  1915. 


152  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

In  1904,  a  new  structure  was  completed  at  the  quarantine  station  to  receive 
cases  of  small-pox  and  typhus  fever  from  the  city. 

Since  1898,  creditable  studies  concerning  the  occurrence  and  distribution  of 
diphtheria,  scarlet  fever,  small-pox,  typhoid  fever,  tuberculosis,  and  pneumonia 
have  been  made  by  Dr.  C.  Hampson  Jones  and  Dr.  William  Eoyal  Stokes. 

A  system  of  medical  inspection  of  school  children  was  inaugurated  in  1905, 
and  in  1910  a  division  of  tuberculosis,  with  nurses  and  dispensaries,  wras 
established. 

Since  the  health  department  by  1898  was  committed  to  the  theory  that  the 
spread  of  diseases  regarded  as  distinctively  communicated  by  contact  from  one 
person  to  another  is  controllable  by  isolation  of  the  sick  and  disinfection  or 
destruction  of  their  contactive  environment  and  deliberately  set  out  to  base 
administrative  practice  upon  this  theory,  it  becomes  necessary  to  examine  both 
the  possibilities  and  the  results  as  measured  in  actual  control  of  these  diseases. 
The  century-old  plan  comprehends  early  and  complete  isolation  of  the  affected 
and  his  contacts  and  disinfection  by  physical  and  chemical  means  of  his  con¬ 
tactive  environment. 

It  has  been  pointed  out  that  before  1898,  except  in  connection  with  small-pox 
and,  on  occasion,  typhus  fever,  the  health  department  pursued  a  policy  of 
laissez-faire ,  most  measures  to  this  end  being  undertaken  on  the  initiative  of 
the  family  physician  or  the  family  of  the  affected.  With  the  exception  of  small¬ 
pox  and  typhus  fever  (when  not  prevalent  in  excessive  degree),  adequate  facili¬ 
ties  for  hospitalization  of  more  than  the  merest  fraction  of  the  total  number  of 
cases  of  scarlet  fever,  diphtheria,  whooping-cough,  measles,  epidemic  meningi¬ 
tis,  poliomyelitis,  typhoid  fever,  cholera,  and  pulmonary  tuberculosis  have  never 
been  available  to  the  health  department.  For  these  diseases,  therefore,  such 
isolation  as  it  has  been  possible  to  attempt  has  been  confined  for  practicable  pur¬ 
poses  to  the  households  or  institutions  in  which  the  patients  were  domiciled. 
Since  an  overwhelming  majority  of  families  live  in  dwellings  of  not  over  six 
rooms,  with  but  one  bath  and  toilet  room,  and  the  mother  does  the  cooking  and 
household  work,  with  only  the  help  that  older  children  or  other  members  of 
the  family  are  able  to  give,  complete  isolation  of  the  sick  is  manifestly  impos¬ 
sible  in  most  homes.  Since  nearly  all  of  the  institutions,  including  orphan  asy¬ 
lums,  hospitals,  and  the  like,  until  the  last  three  or  four  years,  have  lacked 
adequate  rooms  and  other  facilities  for  isolating  those  sick  of  the  communicable 
diseases,  those  diseases  which  readily  spread  by  contact  when  once  present  are 
apt  to  run  their  courses  but  lightly  influenced  by  restrictive  measures.  Measles, 
whooping-cough,  diphtheria,  scarlet  fever,  mumps,  and  chicken-pox,  the  more 
common  diseases  of  this  category  and  the  ones  which  are  particularly  apt  to  be 
transferred  to  others  during  the  prodromal  or  incubative  stages,  have,  therefore, 
in  the  great  bulk  of  the  homes  and  in  most  institutions  defied  the  attempts  of 
physicians  and  the  health  department  to  prevent  their  spreading  to  all  or  to 
most  of  the  susceptibles  within  their  walls.  As  is  well  known,  in  families  with  the 
largest  houses  and  the  most  favorable  conditions  of  structure  and  service,  these 
diseases,  when  introduced,  commonly  spread  to  the  susceptibles  at  will.  The 
same  is  equally  true  of  epidemic  meningitis  and  of  poliomyelitis.  It  is  clear, 
therefore,  that,  in  the  nature  of  things,  the  most  that  can  be  hoped  for  is  to 
restrict  these  particular  diseases  to  the  members  of  the  household.  For  some 
years  the  health  department  has  permitted  and  even  encouraged  the  sending  of 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


153 


children  exposed  in  their  homes  to  scarlet  fever,  measles,  and  mumps  to  the 
homes  of  relatives  or  friends  without  children,  under  proper  restriction.  As  a 
matter  of  fact,  in  the  ordinary  household  or  institution  with  children  and 
young  adults,  it  is  with  few  exceptions  the  rule  in  Baltimore,  as  elsewhere,  for 
measles,  whooping-cough,  mumps,  and  chicken-pox,  when  introduced,  to  attack 
all  the  susceptibles  either  at  once  or  in  rotation,  and,  in  the  case  of  diphtheria, 
for  a  large  percentage  of  those  exposed  to  develop  the  carrier  state  at  least. 
With  scarlet  fever,  under  similar  circumstances,  it  is  not  uncommon  for  several 
or  for  all  of  those  theoretically  susceptible,  i.  e.,  under  20  years  of  age  and  not 
protected  by  a  previous  attack,  to  escape,  even  when  contact  with  the  sick  has 
been  close.  The  same  holds  true  usually  for  poliomyelitis  and  for  epidemic 
meningitis  in  ordinary  years,  though,  in  regard  to  the  latter  disease,  a  con¬ 
siderable  proportion  of  the  inmates  are  proven  by  cultures  to  harbor  the  causal 
agent.  In  regard  to  small-pox,  the  danger  of  spread  within  the  family  or  insti¬ 
tutional  population  is  lessened  in  proportion  to  the  number  of  inmates  who 
have  previously  passed  through  attacks  of  small-pox  or  vaccination  and  the 
promptness  with  which  vaccination  and  revaccination  are  instituted.  With 
typhus  fever,  too,  there  existed  little  chance  of  preventing  spread  within  a 
dwelling  in  which  the  disease  appeared.  In  exceptionally  large  houses  of  the 
very  rich,  with  ample  service,  and  in  two  hospitals,  the  Johns  Hopkins  Hospital 
and  the  Robert  Garrett  Hospital,  with  satisfactory  provisions  for  the  purpose, 
early  separation  of  those  sick  with  these  affections  has  undoubtedly  on  repeated 
occasions,  but  by  no  means  invariably,  been  followed  by  failure  to  spread. 
Otherwise,  however,  for  the  diseases  under  consideration,  the  sole  effect  possible 
to  be  hoped  for  is  the  prevention  of  their  spread  to  the  outside  population,  by 
interfering  with  the  outgoing  and  ingoing  of  persons  and  the  passage  out  of 
materials.  In  connection  with  typhoid  fever,  until  the  last  few  years,  no 
measures  of  isolation  of  the  sick  or  of  protection  of  those  exposed  were  pre¬ 
scribed  either  in  homes,  hospitals,  or  other  institutions.  No  isolation  of  cases  of 
pulmonary  or  other  forms  of  tuberculosis  within  homes  and  institutions  has  ever 
been  advocated  by  the  Baltimore  Health  Department,  and  no  restriction  (except 
to  forbid  the  handling  of  food  for  sale)  has  been  put  upon  the  free  movements 
of  those  with  open  tuberculous  lesions.  Disinfection  of  sputum  has  not  been 
required.  Since  1905,  under  the  State  law,  fumigation  with  formaldehyde  gas 
of  the  rooms  occupied  by  registered  cases  of  pulmonary  tuberculosis  has  been 
carried  out  after  death  or  removal  for  other  cause. 

In  the  early  days,  houses  harboring  cases  of  small-pox  and  typhus  fever  were 
posted  with  warning  signs,  and  even  guards  were  often  placed  to  prevent  ingress 
and  egress.  These  signs  were  first  posted  on  premises  on  which  were  cases  of 
diphtheria  in  1898,  and  the  use  of  similar  signs  was  instituted  for  scarlet  fever, 
measles,  whooping-cough,  chicken-pox,  mumps,  epidemic  meningitis,  and  poli¬ 
omyelitis  in  later  years.  As  late  as  1915  this  was  done,  except  in  cases  of  diph¬ 
theria  and  scarlet  fever,  with  no  regularity. 

Small-pox  is  the  only  disease  for  which  the  health  department  has  consis¬ 
tently  practiced  removal  to  hospitals,  but  in  times  of  considerable  epidemics 
facilities  were  not  at  hand  to  hospitalize  half  the  cases  discovered.  Cases  of 
typhus  fever,  during  the  great  prevalence  of  the  disease  in  the  first  three 
quarters  of  the  nineteenth  century,  were  sent  to  the  department’s  hospitals  in 
large  numbers,  but  apparently  more  for  the  better  care  of  the  destitute  sick  than 


154  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

as  a  method  of  disease  restriction,  for  cases  were  often  sent  to  the  open  wards 
of  the  almshouse  infirmary.  Since  1900  at  least,  the  rare  cases  of  typhus  fever 
have  been  hospitalized  primarily  as  a  protection  to  the  rest  of  the  community. 
The  relatively  small  number  of  beds  in  the  Sydenham  Hospital  has  been  ade¬ 
quate  to  accommodate  so  small  a  proportion  of  the  cases  of  diphtheria,  scarlet 
fever,  or  measles,  occurring  within  the  city,  that  its  use  has  practically  been 
limited  to  the  care  of  severe  cases  of  these  diseases  happening  under  home  con¬ 
ditions  particularly  unfavorable  for  treatment.  As  an  isolation  hospital  in  the 
true  sense  of  the  term,  it  can  not  for  these  diseases  be  said  to  exist.  It  has  very 
occasionally  been  used  in  this  sense  for  cases  of  poliomyelitis  and  epidemic  men¬ 
ingitis.  Compulsory  hospitalization,  except  very  occasionally,  lias  never  been 
practiced  in  Baltimore  for  cases  of  typhoid  fever. 

It  has  been  shown  that  the  system  of  school  inspection  practiced  could  not 
by  any  chance  be  credited  with  any  material  effect  in  the  control  of  any  com¬ 
municable  diseases,  except  in  so  far  as  it  assured  the  enforcement  of  vaccination 
and  has  assisted  in  the  gradual  delousing  of  the  population. 

That  warning  signs  have  exercised  a  helpful  effect  in  keeping  the  more 
enlightened  part  of  the  community  from  contact  with  cases  of  communicable 
diseases  is  certain,  but  it  is  no  less  certain  that  they  have  had  no  restraining 
influence  upon  a  considerable  section  of  the  population.  The  same  may  be  said 
concerning  restrictions  sought  to  be  imposed  upon  the  inmates  of  houses  harbor¬ 
ing  communicable  diseases  from  mingling  with  the  neighbors  and  the  public. 
If  the  neighbors  are  in  sympathy,  they  mingle  freely;  if  they  are  opposed, 
whether  on  account  of  fear  or  wish  to  support  the  law  and  the  authorities,  the 
offenders  are  reported,  and  actions  are  taken  by  the  department  to  enforce  its 
regulations.  It  is  probable  that  in  some  degree  more  or  less  serious,  the  regu¬ 
lations  of  the  health  department  in  regard  to  household  quarantine  are  broken 
in  at  least  the  majority  of  instances. 

From  the  beginning,  the  discharge  of  patients  and  contacts  from  isolation 
in  the  case  of  small-pox  and  typhus  fever  has  been  rather  rigidly  supervised  and 
controlled  by  the  health  department.  For  other  diseases,  the  discharge  was  at 
the  discretion  of  the  physician  in  charge  until  1898,  when  the  health  depart¬ 
ment  assumed  entire  charge  of  the  matter  through  the  health  wardens.  Since 
1898,  the  health  warden’s  certificate  has  been  required  of  children  and  teachers 
returning  to  school  after  isolation  for  small-pox,  typhus  fever,  diphtheria,  scar¬ 
let  fever,  measles,  mumps,  chicken-pox,  and  whooping-cough.  In  1917,  epidemic 
meningitis  and  poliomyelitis  were  added  to  this  list.  The  discharge  of  cases  of 
diphtheria  and  of  diphtheria  carriers  since  1896  and  of  cases  of  epidemic  men¬ 
ingitis  and  meningo-coccus  carriers  since  1917  has  been  controlled  by  culture 
tests.  In  regard  to  all  other  diseases,  the  date  of  discharge  of  the  recovered  and 
of  contacts  has  been  governed  in  the  case  of  the  former  by  arbitrary  and  varying 
standards,  and  in  the  case  of  the  latter  by  the  average  length  of  the  incubation 
period.  Since  1916,  typhoid  carriers  have  been  forbidden  to  prepare  or  other¬ 
wise  handle  food  for  others. 

The  Baltimore  health  department  has  never  inaugurated  a  single  administra¬ 
tive  measure  directed  at  the  control  of  the  venereal  diseases.  Under  the  regu¬ 
lations  of  the  State  Department  of  Health  of  1894,  applying  to  the  whole  State, 
cases  of  ophthalmia  of  the  newborn,  commonly  gonorrhoeal  in  origin,  have  been 
reported,  and  the  department  has  been  active  in  enforcing  prompt  treatment, 
but  entirely  from  the  standpoint  of  restricting  blindness.  In  regard  to  the 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


155 


venereal  diseases  in  their  usual  forms,  from  either  the  standpoint  of  prevention 
or  cure,  it  has  never  inaugurated  a  single  activity.  An  ordinance  designed  to 
prevent  promiscuous  sexual  intercourse  in  boarding  and  lodging  houses,  apart¬ 
ments,  and  hotels  was  passed  in  1918  at  the  insistence  of  the  United  States 
army  officials.  Since  venereal  diseases  were  made  reportable  by  resolution  of 
the  State  Board  of  Health  the  same  year,  the  Baltimore  health  department 
has  contented  itself  with  receiving  such  reports  as  were  made  and  with  lend¬ 
ing  its  power,  when  called  upon,  to  force  a  few  recalcitrant  patients  to  appear 
at  the  venereal-disease  clinic  established  by  the  United  States  Government  in 
cooperation  with  the  State  Board  of  Health  and  at  the  clinic  of  the  Johns 
Hopkins  Hospital.  No  effort  was  made  to  establish  clinics  in  the  department, 
to  enforce  the  reporting  of  cases,  or  to  establish  any  machinery  for  their  over¬ 
sight.  Since  1896,  the  bacteriological  laboratory  has  examined  cover-slip 
preparations  for  gono-cocci,  and  since  1916  it  has  made  Wassermann  reaction 
tests  for  physicians. 

The  removal  of  materials  from  dwellings  and  institutions  harboring  cases 
of  communicable  diseases,  though  probably  forbidden  by  the  health  depart¬ 
ment,  was  not  controlled  with  any  certainty  until  recent  years.  Since  milk  has 
been  delivered  in  bottles,  and  before  1910  certainly  no  large  proportion  of 
household  milk  was  so  delivered,  the  health  department  has  seen  to  it  that  empty 
milk  bottles  from  “  infected  99  households  have  not  been  removed  by  milk  dealers 
until  disinfected  under  its  supervision.  Effective  restriction  on  the  sending  of 
laundry  to  washwomen  is  not  possible,  but,  with  the  extensive  development  of 
public  laundries  during  the  last  25  years,  on  account  of  the  cooperation  of  these 
establishments,  danger  of  spreading  diseases  by  means  of  soiled  clothes  from 
such  houses  has  been  greatly  reduced. 

From  the  foregoing  facts  it  is  evident  that  except  for  small-pox  and  typhus 
fever,  so  far  as  the  use  of  methods  under  consideration  are  concerned,  the  Balti¬ 
more  health  department  until  1898  or  thereabout  pursued  a  “  hands  off 99  atti¬ 
tude  in  regard  to  the  diseases  commonly  regarded  as  spread  by  immediate  and 
mediate  contact.  It  is  equally  clear  that  hospitalization  of  the  sick  and  their 
contacts,  on  account  of  the  hopeless  deficiency  of  hospital  accommodations  and 
the  character  of  the  hospitals  used,  can  have  exerted  no  material  influence  in 
checking  the  spread  of  any  of  these  diseases  when  in  epidemic  form,  with  the 
possible  exception  of  small-pox.  It  must  be  quite  patent,  not  only  to  those 
experienced  in  public-health  administration  and  to  physicians,  but  to  those  of 
the  general  public  who  have  had  experience  with  the  course  of  anyone  of  this 
whole  class  of  diseases  under  the  conditions  above  described,  that  the  spread 
of  small-pox,  typhus  fever,  diphtheria,  scarlatina,  measles,  whooping-cough, 
mumps,  chicken-pox,  and  the  like  from  one  individual  to  another  is  rarely 
influenced  by  such  isolation  of  the  sick  and  their  contacts  in  typical  homes  and 
institutions.  Even  in  the  rare  instances  in  which  the  diagnosis  of  the  first  case 
is  made  before  all  the  susceptibles  have  been  exposed,  complete  separation  of  the 
inmates  is  impossible  on  physical  and  personal  grounds.  Therefore  it  would 
appear  that,  under  these  conditions,  even  during  the  few  years  since  about  1910, 
that  a  sustained  effort  has  been  made  by  the  health  department  to  enforce  isola¬ 
tion  of  this  type,  in  but  a  very  small  proportion  of  instances  under  the  most 
favorable  conditions  can  this  procedure  have  restricted  the  number  of  cases 
among  susceptibles  in  the  populations  exposed  in  the  homes  and  institutions 
under  consideration.  For  the  same  reasons,  even  early  hospitalization  of  the 
11 


156  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

first  cases  can  not  be  expected  materially  to  cut  down  the  number  of  primary 
exposures  in  these  groups ;  in  the  nature  of  the  case,  it  can  only,  so  far  as  these 
persons  are  concerned,  lessen  the  risk  run  of  repeated  or  constant  exposure. 
That  the  cutting  off  of  communication  of  the  infected  in  dwellings  by  quaran¬ 
tine  procedures  is  an  effective  measure  and  capable,  when  complete,  of  pre¬ 
venting  the  spread  of  the  causes  of  the  diseases  under  consideration  to  the 
general  community  must  be  acknowledged  upon  a  priori  and  experimental 
grounds.  There  can  be  little  doubt  but  that  in  the  case  of  epidemics  of  small¬ 
pox  and  typhus  fever  when  dwellings  harboring  cases  of  these  diseases  were  ade¬ 
quately  watched  by  reliable  guards  so  that  ingress  and  egress  were  certainly 
prevented,  this  method  has  been  effective.  But  experience  has  shown  that  with¬ 
out  trustworthy  guards,  except  among  the  most  intelligent  and  conscientious 
portion  of  the  population,  on  the  whole  in  the  minority,  complete  isolation  of 
the  sick  and  their  contacts  from  the  general  public  is  not  obtained.  It  is  well 
known  in  the  health  department  that  certain  elements,  by  no  means  small  in 
numbers,  in  the  population  consistently  evade,  or  attempt  to  evade,  regulations 
in  this  regard.  However  this  may  be,  with  the  exception  of  small-pox  and  typhus 
fever,  this  restrictive  measure  was  not  seriously  attempted  in  Baltimore  for  any 
disease  before  1898,  when  it  was  first  applied  to  diphtheria,  scarlatina,  and 
chicken-pox,  to  be  followed  in  later  years  for  whooping-cough,  measles,  mumps, 
meningitis,  and  poliomyelitis.  It  can  not  be  said  that  it  was  generally  done  for 
all  of  these  diseases  before  1916,  or  that  it  was  ever  perfectly  enforced  for  every 
reported  case  of  any  one  of  them. 

In  regard  to  the  value  of  disinfection  by  fire,  heat,  and  chemicals,  it  may  be 
said  that  whatever  virtue  may  reside  in  these  procedures  as  commonly  practiced 
has  been  rewarded  to  Baltimore,  for  small-pox  and  typhus  fever  from  early 
days,  for  diphtheria,  scarlatina,  measles,  and  whooping-cough  since  about  1900, 
and  for  pulmonary  tuberculosis  since  1905.  That  formaldehyde  disinfection  of 
quarters  occupied  by  the  tuberculous,  as  practiced,  could  have  had  any  notable 
influence  upon  checking  the  spread  of  the  cause  of  this  disease  is  beyond  the 
bounds  of  reason.  Only  in  the  last  few  years  has  the  health  department  advised 
disinfection  of  the  discharges  of  typhoid-fever  patients,  and  it  has  never  had 
the  forces  to  see  that  this  advice  has  been  consistently  followed. 

The  effect  of  vaccine  inoculation  upon  the  course  of  small-pox,  of  typhoid 
inoculation  upon  typhoid  fever,  of  anti-rabies  inoculation  upon  hydrophobia, 
and  of  diphtheria  antitoxin  upon  diphtheria  will  be  considered  in  detail  in  the 
separate  discussion  of  these  diseases.  Suffice  it  to  say  here  that  before  1890 
vaccination  against  small-pox  was  never  pushed  to  the  point  of  affording  real 
protection  to  the  population,  that  anti-typhoid  inoculation  has  been  very  little 
practiced,  and  that  there  is  evidence  that  the  use  of  diphtheria  antitoxin  has 
materially  lessened  the  fatalities  from  that  disease. 

The  measures  inaugurated  about  1912  and  brought  to  a  stage  of  precision 
by  1916  to  prevent  the  spread  of  certain  diseases  from  households  harboring 
them  by  removal,  until  disinfected,  of  milk  bottles  and  the  like  must  have  served 
a  useful  purpose,  particularly  in  regard  to  diphtheria,  scarlatina,  and  typhoid 
fever;  but  even  here  the  protection  has  not  been  and  probably  can  never  be 
perfect,  for  the  method  can  not  be  put  into  operation  until  the  cases  are 
reported,  and  before  this  is  done  some  days  (or  even  weeks  in  the  case  of  typhoid 
fever)  have  elapsed  between  the  development  of  the  disease  and  the  application 
of  the  restrictive  measures. 


Chapter  VII. — Administrative  Officers  and  Sub¬ 
divisions  of  the  Health  Department. 


Commissioners  of  health ;  Vaccine  physicians  or  health  wardens ;  Divi¬ 
sion  of  statistics;  Plumbing  division;  Laboratories;  Inspection  of  school 
children;  Nursing  bureau;  Bureau  of  communicable  diseases;  Bureau 
of  infant  welfare;  Miscellaneous  services.  (Tables  7-8.) 

THE  COMMISSIONERS  OF  HEALTH. 

The  early  commissioners  of  health  were  laymen,  and  their  main  duties  were 
to  try  to  keep  the  city  clean  and  to  enforce  the  nuisance  ordinances.  Theirs  was 
to  act  and  not  to  think,  and  from  such  records  as  remain  it  would  seem  that 
they  strove  earnestly  and  honestly  to  perform  their  tasks.  On  medical  questions, 
particularly  in  regard  to  the  management  of  epidemics,  they  were  advised 
until  1821  by  the  health  officer  of  the  port,  and  from  this  date  until  1839  by 
the  consulting  physician. 

Dr.  Thomas  E.  Bond,  consulting  physician  from  1821  to  1829,  was  a  man 
of  eminence  in  his  profession,  and  his  annual  reports  reflected  the  current 
thought  of  his  time.  He  established  public  vaccination. 

Dr.  Horatio  G.  Jameson,  1830  to  1835,  a  student  and  thinker,  and  one  of  the 
most  accomplished  physicians  and  surgeons  of  his  day,  was  probably  the  ablest 
man  ever  at  the  head  of  the  department  of  health  of  Baltimore.  He  urged  com¬ 
pulsory  general  vaccination,  to  be  routinely  applied  in  infancy  and  repeated  at 
puberty.  In  1832  he  decided  that  cholera  is  not  contagious  in  the  usually 
accepted  sense  and  urged  that  it  be  fought  by  a  general  cleaning  up  of  nuisances 
and  the  establishment  of  a  number  of  free  dispensaries  where  the  poor  could 
conveniently  obtain  prompt  treatment  while  the  disease  was  in  the  early  stages. 
He  bitterly  opposed  a  rigid  system  of  quarantine  as  unnecessary  and  hurtful 
to  trade.  Yellow  fever  had  ceased  to  be  a  menace,  diphtheria  and  scarlet  fever 
had  not  yet  assumed  epidemic  prevalence  in  virulent  form,  typhus  fever  wras 
comparatively  quiescent,  and  small-pox  and  malarial  fever  were  regarded  as 
the  chief  problems.  The  former  was  to  be  controlled  by  vaccination  and  the 
latter  by  draining  and  filling  low  places.  Under  his  direction,  and  with  Dr. 
Samuel  B.  Martin  as  health  officer  of  the  port,  the  Baltimore  health  department 
was,  relatively  speaking,  at  its  zenith. 

Dr.  John  Hanson  Briscoe  and  Dr.  Robert  A.  Durkee,  consulting  physicians, 
1836  to  1838  and  1842  to  1844,  respectively,  left  no  evidences  of  particular 
talent  or  activity. 

With  the  revival  of  the  board  of  health  with  medical  representatives  in  1839, 
Dr.  Thomas  E.  Bond  became  the  first  president  and  executive  officer.  He  wras 
succeeded  by  Dr.  Charles  E.  Davis  in  1840  and  1841.  With  its  reestablishment 
in  1845,  the  presidency  of  the  board  was  held  for  six  years  by  Dr.  William  T. 
Leonard,  who  was  succeeded  by  Dr.  S.  R.  Clark,  1851  to  1852.  Dr.  Leonard 
was  a  man  of  some  ability  and  was  particularly  active  in  pushing  vaccination. 

157 


158 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


Dr.  William  H.  Kemp,  as  commissioner  of  health  and  city  physician,  was 
the  head  of  the  department  from  1853  to  1860.  During  the  yellow-fever  epi¬ 
demic  in  the  cities  at  the  mouth  of  the  Chesapeake,  he  kept  up  open  communi¬ 
cation  and  received  refugees.  He  played  an  important  role  in  the  National 
Congress  on  Quarantine  held  in  1856. 

Of  the  next  three  commissioners  at  the  head  of  the  department,  Dr.  Charles 
H.  Bradford,  1861,  Dr.  S.  T.  Knight,  1862  to  1864,  and  Dr.  G.  E.  Morgan, 
1865  to  1870,  Knight  was  the  only  one  of  more  than  ordinary  ability,  and  no 
one  of  them  made  any  signal  improvement  in  methods  or  measures. 

Dr.  Milton  N.  Taylor,  1870  to  1871,  a  respectable  and  amiable  practitioner, 
showed  no  powers  as  an  administrator;  but  his  reports  give  evidence  of  a 
broader  outlook  upon  matters  relating  to  environmental  conditions,  for  he  advo¬ 
cated  the  establishment  of  numerous  small  parks  in  congested  districts  as 
breathing-spaces  for  the  poor  and  the  planting  of  trees  throughout  the  city  to 
afford  shade  in  the  hot  weather  and  as  a  means  of  reducing  surface  and  ground 
water. 

Dr.  George  W.  Benson  was  commissioner  of  health  in  1872  and  1873  and  in 
1882  and  1883,  when  it  fell  to  his  lot  to  fight  two  of  the  most  severe  epidemics 
of  small-pox  in  the  history  of  the  city.  He  was  a  vigorous  and  determined 
administrator  and  left  the  most  complete  and  accurate  records  of  vaccinations 
and  of  reported  cases  to  be  found  in  the  reports. 

Dr.  J ames  A.  Steuart,  who  was  in  charge  of  the  department  as  commissioner 
of  health  from  1873  to  1889,  with  the  exception  of  the  two  years  1882  and  1883, 
devoted  most  of  his  time  and  energies  to  the  work.  With  an  attractive  person¬ 
ality,  a  high  standing  in  the  medical  profession  and  in  the  community,  and  a 
decided  taste  for  the  work,  and  being  well  read  in  the  literature  of  hygiene 
of  his  day,  he  possessed  many  of  the  qualifications  for  leadership  in  public- 
health  administration.  However,  his  deficiency  in  the  requisite  knowledge  of 
the  natural  sciences  and  of  pathological  anatomy  and  his  inability  to  compre¬ 
hend  the  rapidly  growing  literature  of  micro-parasitology  were  handicaps  that 
prevented  his  rising  to  the  full  height  of  his  opportunities.  Thoroughly  con¬ 
vinced  that  most  of  the  communicable  diseases  are  due  to  gaseous  emanations 
from  putrefactive  processes,  early  in  his  adminstration  he  fell  a  complete 
convert  to  the  sewer-gas  theory  of  disease  causation,  and  he  busied  himself 
chiefly  with  increasing  the  machinery  of  the  department  to  deal  with  common 
nuisances,  which  were  multiplying  in  geometric  ratio  to  the  growth  of  the  pop¬ 
ulation.  In  this  field,  his  greatest  contribution  was  the  establishment  of  plumb¬ 
ing  inspection  and  the  employment  of  chemists  to  examine  market  milk  and 
well  and  spring  waters.  He  had  a  decided  interest  in  vital  statistics,  secured  an 
ordinance  requiring  the  certification  of  deaths  and  of  births,  and  was  very  suc¬ 
cessful  in  having  the  latter  recorded.  It  was  during  his  administration  that 
there  was  begun  the  compilation  and  publication  in  the  annual  reports  of  elab¬ 
orate  statistical  tables  of  deaths  expressed  in  absolute  figures.  Dr.  Steuart  laid 
considerable  stress  upon  the  use  of  statistics  in  administration.  Curiously 
enough,  he  made  no  consistent  effort  to  secure  the  reporting  of  cases  of  com¬ 
municable  diseases. 

Dr.  Steuart  was  succeeded  by  Dr.  George  F.  Kohe,  1890  to  1892,  a  man  of 
considerable  talent,  force,  and  executive  ability,  combined  with  a  good  training 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


159 


in  medicine  and  a  taste  for  hygiene,  on  which  he  wrote  a  small  text-book.  Rohe’s 
reports  showed  a  decided  grasp  of  public-health  problems,  and  that  he  did  not 
retain  office  was  a  distinct  misfortune  to  the  city  and  to  the  cause  of  public 
health  in  general.  Had  he  continued  in  office  a  few  more  years  the  city  would 
have  gained  at  least  10  years  in  progress. 

Rohe  was  succeeded  by  Dr.  James  F.  McShane,  a  man  of  more  than  average 
native  ability,  but  of  defective  training  in  the  natural  sciences  and  in  medicine, 
and  but  little  acquainted  with  the  literature  of  his  subject.  He  had  had  the 
advantage,  however,  of  some  years’  experience  as  assistant  commissioner  under 
Steuart  and  Rohe,  from  whom  he  evidently  absorbed  some  ideas.  McShane  was 
open  to  suggestions  from  the  leaders  in  the  medical  profession,  and  his  admin¬ 
istration,  1892  to  1897,  was  marked  by  the  establishment  of  the  laboratories  of 
chemistry  and  bacteriology  in  the  department  and  by  the  recognition  of  the 
importance  of  reporting  communicable  diseases.  He  appreciated  the  necessity 
of  changing  the  traditional  methods  of  the  department.  He  made  some  investi¬ 
gations  into  the  epidemiology  of  typhoid  fever  and  recognized  that  it  may  be 
spread  in  a  variety  of  ways.  He  early  recognized  the  value  of  diphtheria  anti¬ 
toxin  and  secured  its  use  free  of  charge  to  those  unable  to  pay  for  it.  He  had 
no  ideas  of  his  own,  did  not  inspire  confidence,  and  completely  failed  to  attain 
a  position  of  leadership  at  a  time  when  the  leadership  of  a  commissioner  of 
force,  talent,  and  broad  knowledge  would  have  been  of  the  highest  value  to 
the  city. 

Dr.  C.  Hampson  Jones  succeeded  to  the  commissionership  in  1898  and 
brought  to  the  office  native  talent  and  a  real  interest  in  public-health  adminis¬ 
tration,  but  unfortunately,  like  Rohe,  he  held  the  office  for  two  years  only,  a 
time  too  short  to  reorganize  the  methods  and  to  change  the  attitude  of  the 
department  very  materially.  Fortunately  for  the  department,  he  was  retained 
as  assistant  commissioner  from  1900  to  1915  and  was  reappointed  commissioner 
in  the  fall  of  1919. 

Dr.  James  Bosley  wras  commissioner  of  health  from  1900  until  his  death  in 
1913.  A  man  of  considerable  personal  charm  and  a  physician  of  good  repute 
with  a  large  general  practice,  but  untrained  in  pathology  and  in  micro- 
parasitology  at  a  time  when  these  branches  dominated  the  whole  field  of  hygiene, 
and  unacquainted  with  the  literature  of  hygiene,  he  was  almost  entirely  lacking 
in  the  qualifications  necessary  for  the  proper  filling  of  his  office.  He  was  gen¬ 
erally  beloved  in  the  department,  in  which  in  a  short  time  he  became  little  more 
than  a  figurehead.  His  unexpired  term,  from  January  1913  to  October  1915 
was  filled  by  Dr.  Nathan  N.  Gorter,  a  surgeon  of  good  social  and  professional 
standing,  who  was  a  conscientious  official  with  high  aspirations  and  ever  anxious 
to  improve  the  scope  and  efficiency  of  the  health  department.  Without  distinct 
ability  as  an  administrator  or  any  special  knowledge  of  hygiene  and  the  prob¬ 
lems  pressing  for  solution,  he  exercised  no  influence  of  lasting  importance  in 
the  department. 

For  the  18  years  1897  to  1915,  as  commissioner  and  assistant  commissioner, 
Dr.  J ones  was  the  real  force  in  the  department,  and  the  changes  in  the  attitude 
and  the  innovations  in  measures  that  marked  this  critical  period  were  very  clear¬ 
ly  his  contributions.  In  many  matters  he  derived  help  from  the  expert  knowl¬ 
edge  of  his  colleague,  Dr.  Stokes.  Dr.  Jones  was  handicapped  by  lack  of  direct 


160  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

authority  in  the  department  and  had  to  address  the  city  authorities  through 
the  medium  of  the  commissioner.  He  had  to  do  the  work  of  incompetent  com¬ 
missioners  as  well  as  his  own,  much  of  the  time  without  adequate  and  trained 
assistance.  In  consequence,  organization  of  the  department  was  incomplete, 
and  measures  and  methods  formulated  constantly  fell  short  of  his  plans.  Given 
a  free  hand,  with  his  intimate  knowledge  gained  by  long  experience  and  hard 
study  of  the  needs  of  the  department,  Dr.  Jones  might  have  accomplished  much 
more  than  the  very  considerable  reformations  he  instituted. 

The  last  commissioner  of  health  serving  during  the  period  under  review  was 
Dr.  John  D.  Blake,  whose  term  of  office  covered  the  four-year  period  ending  in 
October  1919.  Dr.  Blake,  who  was  a  physician  and  surgeon  of  wide  experience, 
accepted  office  at  a  relatively  advanced  age.  Of  a  genial  nature,  and  with  a 
strict  sense  of  justice  and  probity,  Dr.  Blake  evinced  a  sincere  desire  to  devote 
himself  to  the  public  service.  Like  so  many  of  his  predecessors,  however,  he 
was  untrained  in  public-health  administration,  lacking  in  first-hand  knowledge 
of  micro-parasitology,  and  not  well  versed  in  the  literature  and  methods  of 
modern  hygiene.  Though  considerable  advances  in  the  methods  and  scope  of 
the  work  of  the  department  were  made  during  his  administration  and  he  was 
ever  ready  to  consider  suggestions,  these  handicaps  seriously  impeded  the 
reorganizations  and  readjustments  indicated  by  present-day  knowledge. 

The  main  object  of  this  review  will  be  missed  if  it  has  not  been  made  apparent 
that  the  chief  factor  determining  the  activities  and  accomplishments  of  the 
health  department,  or,  in  other  words,  its  actual  value  to  the  city,  has  been  the 
fitness  of  the  chief  medical  officers.  A  man  of  high  talent,  sound  judgment,  and 
accurate  and  comprehensive  knowledge  to  formulate  appropriate  policies,  and 
force  of  character  to  impress  them  on  the  authorities,  the  profession,  and  the 
general  public  and  gain  the  power  to  carry  them  out,  is  a  tower  of  strength  as 
the  head  of  a  health  department.  Such  a  one  has  been  rare.  Jameson  was  the 
only  man  long  at  the  head  of  the  Baltimore  health  department  who  met  these 
qualifications  in  any  high  degree.  Rohe  might  have  reached  them  in  con¬ 
siderable  degree  had  he  remained  longer  in  office.  The  most  amiable  and  earnest 
commissioner,  lacking  in  knowledge  and  in  capacity  and  desire  to  learn,  may, 
with  the  best  intentions,  set  back  the  clock  for  years.  On  the  other  hand,  most 
of  the  men  at  the  head  of  the  health  department  were,  on  the  whole,  about  as 
useful  and  capable  as  any  who  could  have  been  got  to  serve  under  the  conditions 
obtaining. 

A  great  drag  on  the  logical  development  of  an  intelligent  and  adequate 
public-health  administration  in  Baltimore  has  been  the  indifference,  except  in 
times  of  great  epidemics,  of  the  public  and  of  the  administrative  and  legislative 
authorities  at  certain  periods  of  the  city’s  history,  and  this  has  been  influenced 
to  a  certain  degree  by  the  periods  of  excessive  immigration.  The  dilution 
of  civic  solidarity  by  the  influx  of  people  of  lower  standards  of  intelligence, 
education,  and  living  conditions  must  always  not  only  increase  the  problems 
but  decrease  the  effectiveness  of  administration.  The  continuity  of  plans  and  of 
their  development  is  broken  by  the  necessity  of  meeting  new  and  sudden 
demands,  and  the  influence  of  the  more  progressive  and  intelligent  leaders 
among  the  older  citizenship  is  diffused  over  a  larger  and  less  ductile  mass  and 
consequently  lessened.  The  disgraceful  years  of  rioting,  interference  with 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


161 


voting  by  bands  of  “  plug-uglies,”  and  the  weak  and  corrupt  civic  administra¬ 
tion  of  the  fifth  and  sixth  decades  of  the  last  century  were  intimately  associated 
with  such  a  period  of  massive  immigration.  The  military  government  during 
the  Civil  War,  the  great  losses  to  business  and  commerce  associated  with  that 
war  and  its  consequences,  and  the  long  period  of  political  corruption  and  of 
administrative  inefficiency  that  followed,  reacted  on  public-health  administra¬ 
tion.  The  general  apathy  of  the  public  to  sanitary  improvements  is  well  illus¬ 
trated  by  the  attitude  toward  establishing  a  system  of  sanitary  sewers,  repeat¬ 
edly  proposed,  and  toward  the  water-supply.  During  these  periods  only  men  of 
extraordinary  power  could  have  exerted  a  decided  influence  in  the  health  office. 
Another  great  setback  in  one  sense,  but  of  some  general  sanitary  gain  in  another, 
was  the  great  fire  of  1904.  The  energies  of  mayors  of  a  type  decidedly  above 
their  immediate  predecessors,  which  might  have  been  devoted  to  sanitary 
reforms  and  the  placing  of  stronger  men  in  the  health  department,  were  thus 
diverted  to  other  directions. 

While  many  of  the  mayors  of  Baltimore  were  men  of  distinct  ability  and  none 
of  them  were  lacking  in  concern  for  the  general  welfare,  it  is  a  fact  of  impor¬ 
tance  that  comparatively  few  of  them  evinced  a  continuing  interest  in  and  a 
critical  insight  into  the  problems  of  public-health  administration.  Of  those 
who  exhibited  these  qualities,  Dr.  Edward  Johnson,  1818  to  1822,  and  Mr. 
James  H.  Preston,  1911  to  1919,  stand  out  conspicuously.  The  former  was 
deeply  concerned  in  the  measures  for  the  restriction  of  yellow  fever  and  malaria. 

Another  serious  drag  on  development  of  ideas  and  improvement  in  measures 
and  methods  in  the  health  department  was  the  distinct  lowering  of  the  standard 
of  the  medical  profession  of  the  city  after  1870,  traceable  to  the  growth  and 
influence  of  the  proprietary  medical  schools  that  flourished  between  1872  and 
1910.  Many  of  the  medical  graduates  turned  out  were  for  their  times  relatively 
much  inferior  in  intellect,  general  and  professional  education,  and  standards 
than  the  men  whom  they  replaced. 

SUBORDINATES  IN  THE  HEALTH  DEPARTMENT. 

While  in  the  early  years  subordinates  in  the  health  department  may  have 
been  carefully  selected  for  personal  fitness  for  their  work,  there  is  nothing  in 
the  records  to  show  that  this  was  generally  true.  So  far  as  tradition  goes,  with 
a  few  exceptions,  appointments  to  all  offices  from  commissioner  down  have 
been  governed  by  partisan  politics.  Of  late  years  reformers  and  aspirants  for 
political  advancement  have  dwelt  upon  this  point,  and  it  has  been  freely 
acknowledged  by  the  professional  politicians.  The  professional  politicians,  in 
a  sense,  act  as  employment  agencies;  but,  unlike  the  usual  agencies  for  this 
purpose,  they  assume  a  double  responsibility,  for  they  must  to  a  considerable 
degree  look  out  for  the  interests  of  both  employer  and  employee.  The  usual 
business  agency  is  interested  primarily  in  getting  a  job  for  the  employee,  but 
the  politicians  have  a  direct  interest  in  seeing  that,  to  some  degree  at  least,  the 
employer  is  not  illy  served.  The  history  of  the  health  department  shows  that  a 
large  number  of  employees,  appointed  primarily  on  political  grounds,  have 
been  faithful,  conscientious,  hard-working,  and  intelligent  servants  of  the 
public  for  years,  with  a  commendable  pride  in  their  work,  at  which,  in  times 
of  stress,  they  have  slaved  for  long  hours  overtime  without  a  murmur,  without 


162  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

any  chance  of  extra  pay,  and  without  public  recognition.  For  many  years,  for 
positions  requiring  technical  skill  and  training,  as  the  heads  of  the  laboratories 
of  chemistry  and  bacteriology,  for  instance,  the  incumbents  have  been  chosen 
primarily  for  these  qualities.  Many  valuable  assistants  have  been  trained  in 
these  laboratories  from  promising  material  and  given  the  chance  of  advance¬ 
ment  to  higher  posts  on  pure  merit.  Some  of  them  have  been  called  away  to 
more  remunerative  positions  in  industries  and  made  way  for  others  to  rise  in 
their  places.  The  heads  of  the  division  of  plumbing  have  always  been  master 
plumbers  of  honesty  and  capacity  and  have  so  conducted  the  work  that  dis¬ 
honesty  soon  becomes  glaring  and  meets  its  just  reward  and  shirkers  are 
crowded  out. 

That  there  were  many  incompetents  and  a  considerable  number  of  misfits 
there  is  no  question,  but  actual  practical  work  in  the  department  was  the  only 
school  available  to  subordinate  employees,  and  only  the  few  can  grasp  the 
details  of  new  labors  without  careful  oversight  and  instruction,  and  under  no 
system  of  appointment  will  the  lazy  exert  themselves  without  prodding.  Where 
subordinates  have  this  treatment  from  an  immediate  superior,  backed  by  the 
commissioner,  good  service  to  the  city  has  commonly  resulted. 

The  defects  in  the  administration  of  the  health  department  are  not  explained 
satisfactorily  on  the  common  assumption  that  they  were  due  in  the  main  to  the 
inefficiency  of  subordinates  steeped  in  partisan  politics  and  forced  on  an  un¬ 
willing  commissioner  by  political  bosses.  To  a  degree  not  generally  recognized, 
the  commissioners  have  been  responsible  for  these  short  comings.  It  is  the 
duty  of  a  commissioner  of  health  to  set  policies  and  standards,  to  train  his 
personnel,  and  to  see  that  the  work  is  done  promptly  and  affectively,  that  misfits 
— unavoidable  under  any  system  of  appointment — are  properly  placed,  and  that 
the  incompetent  and  the  shirker  are  weeded  out.  Too  often  has  a  commissioner 
failed  in  one  or  more  of  these  respects  and  it  has  fallen  to  the  lot  of  the  assis¬ 
tant  commissioner,  without  power  to  inaugurate  or  to  change  policies  and  to 
promote  or  demote  subordinates,  to  attempt  to  discharge  the  duties  of  two  men. 

THE  VACCINE  PHYSICIAN  AND  THE 
HEALTH- WARDEN  SYSTEM. 

In  1821,  in  order  “  to  extend  the  benefits  of  vaccination  ”  to  the  poor  and 
probably  with  the  design  of  relieving  the  members  of  the  Medical  and  Chirurgi- 
cal  Faculty  of  a  burden  which  they  had  voluntarily  assumed,  an  appropriation 
of  $400  was  made  by  the  city  for  the  appointment  in  the  health  department  of 
four  public  vaccinators  to  be  called  vaccine  physicians.  The  system  was  organ¬ 
ized  and  the  physicians  were  chosen  by  a  committee  of  the  faculty.  As  at  first 
intended  and  practiced,  there  was  no  compulsion  exercised  on  the  public  to 
submit  to  vaccination  by  these  four  physicians;  their  services  were  freely 
extended  to  those  who  desired  them  but  who  could  not  afford  to  pay  the  charges 
of  private  practitioners.  The  vaccinators  made  monthly  reports  to  the  health 
department  of  the  number  of  vaccinations  made  and  of  their  success  or  failure. 
It  was  not  until  the  small-pox  epidemic  of  1831  that,  in  addition  to  their  origi¬ 
nal  duties  and  as  part  of  the  administrative  program  of  the  department  against 
this  disease,  they  were  ordered  to  vaccinate,  nolens  volens ,  the  contacts  of  cases 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


163 


of  6mall-pox  and  were  detailed  to  make  a  house-to-house  canvas  for  hidden  cases. 
In  1827,  the  number  of  vaccinators  was  raised  to  six  and  in  1831  it  was 
doubled,  one  for  each  city  ward. 

By  ordinance  of  1853,  it  was  made  the  additional  duty  of  the  vaccine  physi¬ 
cians  to  be  on  the  outlook  for  cases  of  any  “  pestilential  ”  disease  and  for 
nuisances  dangerous  to  health  in  their  wards,  which  they  were  to  report  to  the 
health  office.  By  the  charter  of  1900,  a  vaccine  physician  for  each  ward  was 
prescribed,  who,  in  addition  to  his  other  duties,  was  to  act  as  health  warden, 
and  thus  the  vaccine  physicians  were  raised  officially  to  the  status  of  wardens 
of  health.  Their  duties  were  very  much  expanded  in  the  eighth  decade  of  the 
last  century,  when  vaccination  was  made  compulsory  and  an  ever-increasing 
proportion  of  the  people  availed  themselves  of  the  privilege,  now  extended  to 
every  one,  of  free  vaccination.  When  the  street-cleaning  and  garbage  and  ash 
removal  were  taken  out  of  the  health  department  and  its  nuisance  force  was 
thereby  cut  down  to  a  minimum,  the  health  warden  gradually  evolved  from  a 
reporter  to  an  abater  of  nuisances  of  various  sorts.  The  health  wardens  were 
relieved  of  some  of  the  latter  duties  by  the  inspectors  of  nuisances  until  1895, 
but  from  this  date  until  1916  the  chief  function  of  the  health  warden  was  the 
control  of  ordinary  nuisances,  and,  in  many  wards,  the  inspection  of  cellars, 
yards,  toilets,  privies,  leaking  pipes  and  rain  gutters,  and  dirty  and  ill-paved 
yards,  alleys,  and  streets  obscured  their  medical  activities.  The  latter  were 
much  expanded  during  and  after  the  commissionership  of  Dr.  C.  Hampson 
Jones  in  1898,  when  concerted  efforts,  very  largely  carried  out  by  the  health 
wardens,  were  instituted  against  various  communicable  diseases. 

Since  1916,  the  nuisance  work  of  the  health  warden  has  been  considerably 
abridged,  partly  because  of  the  improved  grading  and  paving  of  streets  and 
alleys  and  the  completion  of  the  dual  sewage  system,  and  partly  because  of  the 
shifting  of  most  of  it  to  the  division  of  plumbing.  He  has  in  consequence  been 
restored  to  his  original  status  of  medical  officer  of  health  in  his  ward,  in  charge, 
under  the  direction  of  an  assistant  commissioner  of  health,  of  public  vaccination 
and  of  other  activities  directed  to  the  control  of  diseases  transmissible  by  per¬ 
sonal  contact.  To  this  end  he  must  visit  each  reported  case,  give  instructions, 
establish  isolation  in  homes  and  institutions,  take  cultures,  make  diagnoses, 
issue  discharge  certificates,  and  obtain  and  file  a  history  of  each  case. 

The  vaccine  physicians  and  health  wardens  always  have  been  physicians  in 
active  practice,  giving  so  much  of  their  time  to  the  work  of  the  department  as 
was  demanded.  Their  salary  has  always  been  incommensurate  to  the  time 
devoted  and  the  character  of  the  services  rendered,  and,  owing  to  lack  of  proper 
organization  of  the  work  of  the  department,  much  of  their  time  has  been  wasted 
unnecessarily. 

The  health  wardens  and  the  system  have  been  much  criticized  and  maligned, 
particularly  by  the  unthinking  and  the  uninformed  of  a  class  that,  recognizing 
that  something  was  radically  wrong  with  the  department  and  believing  that  all 
the  evils  affecting  mankind  center  in  the  nuisances  the  health  wardens  were  sup¬ 
posed  to  abate  (an  impossible  task  under  the  physical  conditions  obtaining), 
laid  the  defects  at  their  door.  As  a  matter  of  fact,  the  typical  vaccine  physician 
or  health  warden  has  always  been  a  physician  of  more  than  the  average  intel¬ 
ligence,  training,  diagnostic  ability,  and  knowledge  of  the  natural  history  of 


164  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

disease,  and  certainly,  in  knowledge  and  experience  in  Ills  work,  the  superior 
of  any  commissioner  of  health  between  1900  and  1919.  Many  able  physicians, 
such  as  G.  W.  Miltenberger,  Frank  Donaldson,  Charles  Frick,  William  F.  Lock- 
wood,  N.  G.  B.  Iglehard,  for  instance,  who  afterwards  reached  distinction,  did 
not  scorn  the  office  in  their  earlier  years. 

DIVISION  OF  STATISTICS. 

Since  the  establishment  of  the  health  department  the  records  of  deaths,  since 
1875  the  records  of  births,  and  since  1882  the  records  of  reported  cases,  have 
been  kept  by  clerks  under  the  supervision  of  the  chief  medical  officer.  For  many 
years  the  records  of  births,  and  deaths,  and  cases  have  been  kept  and  tabulated 
in  separate  divisions.  In  both  form  and  content  the  general  and  special  tabula¬ 
tions  published  in  the  annual  reports  have  been  directed  and  supervised  by  the 
commissioners  or  by  the  assistant  commissioners  of  health.  Neither  the  statis¬ 
tical  clerks  nor  their  supervisors  have  had  formal  training  in  statistical  methods 
and  their  competence  has  not  extended  beyond  the  capacity  to  follow  with  con¬ 
scientious  fidelity  the  customs  and  rules  of  classification  of  deaths,  births,  and 
reported  cases,  to  perform  addition  correctly,  to  set  up  simple  tables,  and  to 
calculate  crude  rates. 


DIVISION  OF  PLUMBING. 

When  supervision  of  plumbing  was  first  provided  for  in  1883,  with  provision 
for  an  inspector  with  power  to  frame  proper  rules  therefor,  subject  to  the 
approval  of  the  Board  of  Health,  the  evident  intent  of  the  law  was  to  limit 
operations  to  new  installations.  But  the  inspector  soon  found  many  nuisances 
in  connection  with  old  installations,  which  were  reached  under  the  general 
powers  of  the  board.  These  nuisances  were  associated  chiefly  with  poor  design 
and  materials  and  lack  of  repair,  giving  rise  to  odors,  leaks,  and  overflows, 
both  within  and  without  dwellings.  These  conditions  and  their  causes  and 
proper  remedies  were  ably  treated  and  illustrated  with  drawings  by  the  inspector 
of  plumbing,  John  W.  Lee,  in  his  report  for  1886.  Among  other  things  he  found 
to  condemn  were  lack  of  vents  for  privy-wells,  the  filthy  condition  of  water- 
closets  and  bath-tubs,  often  inclosed  with  foul-smelling  and  rotten  woodwork, 
and  the  use  of  the  old  pan  type  of  water-closet.  Strongly  convinced  of  the 
potency  of  sewer-gas  as  the  prime  cause  of  acute  diseases,  and  backed  by  a 
commissioner  wedded  to  this  theory,  he  set  to  work  to  rectify  these  conditions. 
From  the  beginning,  therefore,  the  activities  of  the  plumbing  division  have  been 
to  regulate  and  correct  existing  nuisances  by  ordering,  where  deemed  necessary, 
repairs  or  renewals  amounting  to  new  installations,  to  see  to  it  that  all  new 
installations  were  in  design,  material,  and  workmanship  proper  for  their 
purpose.  These  factors,  of  course,  led  to  the  establishment  of  standards  on  which 
permits  for  work  were  based,  and  of  a  system  of  inspection  of  work  in  progress 
to  see  that  these  standards  were  met. 

It  is  a  matter  of  interest  that  the  plumbing  department  has  sought  to  protect 
the  property-holder  by  insisting  that  plumbing  work  shall  be  done  in  a  “  work¬ 
man-like  ”  manner,  that  is,  according  to  the  standards  of  ethics  and  practice 
recognized  as  proper  in  the  trade.  A  second  activity  of  importance  was  the 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


1G5 


system  of  inspection  of  complaints,  involving  advice  and  requirements  for 
the  abatement  of  nuisances  connected  with  plumbing,  and  covering  a  great 
variety  of  conditions.  A  third  duty  was  the  clearing  of  stoppages  of  public  and 
private  sewers,  and  to  a  certain  degree  the  oversight  of  cesspools.  By  1898  the 
duties  and  standards  of  the  plumbing  department  had  reached  a  point  where 
the  commissioner  of  health  felt  warranted  in  issuing  a  set  of  rules  and  regula¬ 
tions,  which  had  the  effect  of  a  code  of  plumbing.  The  section  on  plumbing 
of  the  building  code  of  1908  represents  an  expansion  of  these  regulations. 

With  the  partial  completion  of  the  new  sewage  system  in  1911,  the  work  of 
the  division  of  plumbing  was  enormously  increased,  and  the  personnel  was  corre¬ 
spondingly  expanded,  to  force  and  to  oversee  connections.  The  sewer  laterals 
were  extended  to  the  building-line  of  each  property,  and  all  connections  thereto 
were  made  under  the  supervision  of  the  division  of  plumbing.  This  work, 
which  required  an  immense  amount  of  detailed  planning  and  supervision  and 
considerable  executive  ability,  was  pushed  when  the  sewers  were  ready  for  con¬ 
nections  and  was  successfully  completed  for  the  sewered  districts  in  1918. 

The  annual  reports  and  observation  of  their  work  and  methods  show  that 
the  successive  chief  inspectors  of  plumbing  have  been  faithful  public  servants, 
men  of  integrity,  judgment,  and  courage,  who  have  well  filled  positions  of 
responsibility. 

LABORATORIES. 

The  establishment  of  the  laboratories  of  chemistry  and  of  bacteriology  in 
the  health  department  dates  from  1896.  Though  started  under  different 
conditions  and  maintained  always  as  separate  departments,  their  work,  while 
remaining  separate  and  distinct  in  certain  fields  of  activity,  soon  became  closely 
interwoven. 

CHEMICAL  LABORATORY. 

The  laboratory  of  chemistry  evolved  by  slow  stages,  under  the  needs  of  the 
commissioners  of  health  for  expert  advice  and  assistance  in  attempts  to  improve 
and  control  the  milk  and  water  supplies.  This  began  with  the  employment  of 
Professor  William  P.  Tonry,  of  the  Maryland  Institute,  by  Commissioner 
Steuart,  to  examine  samples  of  milk  in  1873  and  of  well  and  spring  waters  in 
1876  and  1885.  As  a  result  of  these  examinations,  Commissioner  Steuart 
started  a  campaign  against  city  wells  in  1876.  In  1892,  Commissioner  McShane 
employed  another  chemist,  Professor  P.  D.  Wilson,  to  conduct  examinations 
of  the  waters  of  streams  tributary  to  the  Lake  Roland  water-supply. 

Though  Professor  Tonry’s  valuable  reports  on  the  milk  supply  in  1873 
showed  that  much  of  the  milk  was  deficient  in  butter  fats,  watered,  and  filled 
with  impurities,  no  steps  were  taken  by  the  city  government  to  furnish  the 
commissioner  of  health  with  means  and  personnel  to  enforce  the  weak  ordinance 
of  1855  and  the  similar  ordinance  of  1879,  forbidding  the  mixing  of  water  and 
any  drug  with  milk  offered  for  sale. 

Dr.  Tonry  was  appointed  chemist  to  the  health  department  in  1894,  under 
the  provisions  of  the  food  ordinance  of  that  year.  He  used  his  private  laboratory 
until  1896,  when  provision  for  a  small  chemical  laboratory  in  the  health  depart¬ 
ment  was  made.  Dr.  Tonry  made  a  comprehensive  study  of  the  sources  of  the 
Baltimore  milk-supply,  the  conditions  under  which  it  was  produced,  handled, 


166  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

and  sold,  and  started  a  system  of  inspection  to  prevent  adulteration  by  addition 
of  water,  adulterants,  and  preservatives.  An  important  part  of  his  work  was 
the  organization  of  inspection  and  improvement  of  cow  stables,  and  the  feeding 
of  milch  cattle,  which  finally,  by  making  it  unprofitable,  served  to  force  most  of 
these  places  to  discontinue  operations.  Examination  of  well  and  spring  waters 
was  inaugurated,  and  of  preserved  foods,  to  which  suspicion  was  directed. 

In  1895,  the  cause  of  the  sudden  illness  of  17  people  was  proven  to  be  due 
to  arsenic  present  in  a  barrel  of  pickles  sold  at  a  grocery. 

The  reports  of  Dr.  George  W.  Lehmann,  who  succeeded  Professor  Tonry  in 
1896,  show  that  creditable  work  was  done  in  inspection  and  analysis  of  the 
milk  and  water  supplies.  In  1896,  the  work  of  food  inspection  was  expanded 
by  adding  inspection  of  bakeries  and  confectioneries,  and  in  1900  this  inspection 
was  extended  to  markets  and  slaughter-houses,  resulting  in  the  condemnation 
of  large  quantities  of  meats  and  vegetables  as  unfit  for  food. 

By  the  gradual  addition  of  inspectors  and  the  reference  to  them  by  the  com¬ 
missioner  of  health,  usually  on  complaint  of  citizens,  of  different  types  of  food 
for  examination,  the  chemist  became  the  head  of  an  administrative  department, 
guarding  the  purity  of  the  food-supply.  Where  legal  standards  established  by 
ordinance  or  by  state  legislature  were  lacking,  they  were  supplied  by  ukase  of 
the  commissioners  of  health.  The  reports  of  chemical  determinations  and  of 
inspections  and  condemnations  made  are  full  and,  for  the  purposes  of  sanitary 
administration,  very  informing.  In  1903,  an  extensive  inquiry  was  made  into 
the  adulteration  of  milk  sold  in  small  stores,  particularly  for  the  use  of  the 
babies  of  the  poor,  and  into  the  quality  and  composition  of  condensed  milk  used 
for  this  purpose.  It  was  calculated,  from  the  number  of  cans  of  the  latter  sold, 
that  at  least  960,000  gallons  of  this  material  in  the  dilutions  recommended  by 
the  manufacturer  were  used  each  year  in  the  city.  Pus  organisms  and  other 
bacteria  being  present  in  numbers  in  samples  from  original  packages,  and  the 
chemical  analysis  showing  evidences  of  adulteration,  standards  of  purity  for 
condensed  milk  were  set  and  enforced. 

The  activities  of  the  department  had  been  expended  by  1910  to  include 
inspection  of  dairy  farms  supplying  milk  to  the  city  and  supervision  of  the 
pasteurization  of  milk  and  cream  (a  considerable  number  of  dealers  having 
voluntarily  adopted  pasteurization),  better  control  of  the  physical  conditions 
under  which  milk  was  handled  and  sold  (especially  the  general  sanitation  of 
small  milk  shops),  and  the  inspection  of  meats  and  meat  products  at  slaughter¬ 
houses.  At  the  same  time,  the  chemical  analysis  of  foods  and  drugs  for  adultera¬ 
tion  had  expanded. 

By  1915  the  chemist  presided  over  a  bureau  of  chemistry  and  food  inspection, 
with  several  assistants  and  a  large  force  of  inspectors.  There  were  analyzed 
regularly  the  city  water,  the  milk,  cream,  ice-cream,  condensed  milk,  canned 
and  prepared  foods,  and  the  like.  Dairy  farms,  dairies,  milk-wagons,  slaughter¬ 
houses,  wholesale  and  retail  markets,  stores,  bakeries,  and  confectioneries  were 
inspected  and  pasteurization  of  milk  was  supervised.  The  scope  of  the  meat 
and  dairy  and  milk  inspection  and  of  the  water  control  are  considered  in  other 
chapters. 

The  most  useful  work  of  this  division  of  the  health  department  has  undoubt¬ 
edly  been  in  connection  with  water  and  milk,  and  of  all  the  activities  in  this 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


167 


relation,  the  enforcement  of  the  milk  ordinance  of  191?  was  perhaps  its  most 
significant  accomplishment  of  value.  Viewing  this  work  from  the  standpoints 
of  its  possible,  probable,  and  known  benefit  to  the  public  health,  it  does  not 
appear  that  much  has  been  accomplished  through  the  system  of  dairy-farm 
inspection.  In  adopting  it  and  in  relying  too  heavily  upon  it,  the  department 
followed  the  fashion  of  the  time.  Much  more  would  have  been  accomplished 
with  the  same  force  in  guarding  the  milk-supply  after  its  receipt  within 
the  city. 

The  progress  of  correcting  the  evils  connected  with  the  milk-supply,  while 
slow,  was  in  the  end  effective,  and  each  advancing  step  accomplished  something 
of  value  in  the  direction  of  safeguarding  the  public  health.  To  those  unfamiliar 
with  the  complex  forces,  both  static  and  dynamic,  within  and  without  the  city, 
to  be  overcome  at  each  step,  appreciation  of  the  full  value  of  these  services  is 
impossible. 

In  its  work,  the  division  or  bureau  of  chemistry  has  worked  in  active  coopera¬ 
tion  with  the  bacteriological  laboratory. 

BACTERIOLOGICAL  LABORATORY. 

This  laboratory  was  established  in  1896,  on  the  recommendation  of  Com¬ 
missioner  McShane,  supported  by  a  committee  of  the  'Medical  and  Chirurgical 
Faculty.  The  immediate  stimulus  was  the  recent  discovery  of  the  diphtheria 
antitoxin  and  of  the  culture  method  for  the  certain  and  rapid  diagnosis  of 
diphtheria.  Dr.  William  Royal  Stokes  has  served  continuously  as  bacteriologist. 
This  laboratory  from  the  first  offered  physicians  the  services  of  bacteriological 
methods  for  the  rapid  diagnosis  of  diphtheria,  pulmonary  and  other  forms  of 
tuberculosis,  malaria,  gonorrhoea,  and  certain  other  affections,  and  later,  as 
methods  were  introduced,  of  typhoid  fever,  rabies,  meningitis,  poliomyelitis, 
pneumonia,  and  syphilis.  This  laboratory  has  never  produced  diphtheria  and 
tetanus  antitoxin  and  other  antisera,  nor  vaccine  virus,  but  has  prepared  anti¬ 
typhoid  vaccine  in  large  quantities.  Dr.  Stokes  early  turned  his  attention  to 
bacteriological  analyses  of  the  water-supply  and  of  the  milk  of  Baltimore,  and 
independently  and  in  collaboration  with  the  chemist,  he  has  made  extensive 
and  valuable  studies  of  these.  The  annual  reports  from  this  laboratory  contain 
accounts  of  creditable  studies  and  interpretations  of  their  relation  to  public 
health  in  Baltimore.  Among  the  studies  of  greatest  value  are  those  relating 
to  the  water-supply,  particularly  the  introduction  and  control  of  chlorinization 
in  1911,  and  the  investigations  of  the  presence  of  pus  and  of  pathogenic  organ¬ 
isms  in  milk,  especially  in  relation  to  inflammatory  mastitis  and  tuberculosis 
of  milch  cattle.  The  large  scale  on  which  diphtheria-culture  tests  are  used  in 
the  bureau  of  communicable  diseases  for  release  and  detection  of  possible 
carriers  in  institutions,  schools,  and  homes,  was  made  possible  through 
Dr.  Stokes’s  cooperation  and  largely  on  his  suggestions. 

Throughout  its  history  the  bacteriological  laboratory  has  offered  diagnostic 
and  other  services  far  in  advance  of  their  utilization  by  the  medical  profession 
and  the  public,  and  judged  by  the  character  of  its  accomplishment,  within  the 
limitations  in  means  and  personnel  allowed  it  by  the  city  government,  it  com¬ 
pares  favorably  with  that  of  any  other  city. 


168  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

SCHOOL  INSPECTION. 

School  inspection  started  in  1905  with  2  physicians  and  1  trained  nurse. 
Beginning  in  1906  with  5  physicians  and  5  nurses,  medical  inspection  of  school 
children,  at  first  confined  to  the  public  schools,  was  soon  extended  to  the 
parochial  and  to  some  of  the  private  schools,  and  as  a  routine  matter  it  has 
been  limited  to  children  of  kindergarten  age  and  of  the  first  four  grades  of 
grammar  schools.  The  routine  inspections  have  always  been  restricted  to  physi¬ 
cal  defects,  cleanliness,  and  evidences  of  successful  vaccination.  The  city  is 
divided  into  five  districts,  embracing  approximately  the  same  number  and 
type  of  schools  and  pupils,  and  a  physician  and  nurse  are  assigned  permanently 
to  a  particular  district.  The  physicians  are  allowed  considerable  latitude  as  to 
methods,  but  they  use  the  same  record  forms.  The  usual  procedure,  starting  in 
the  fall,  is  for  the  nurse  to  go  through  the  lower  grades  to  inspect  first  for 
evidences  of  successful  vaccination  and  for  vermin.  Her  attention  is  called  by 
the  teachers  to  those  children  who  obviously  are  defective  in  seeing,  hearing, 
breathing,  or  who  in  any  other  way  seem  abnormal,  and  in  addition  the  nurse 
looks  and  inquires  for  children  with  chronic  coughs,  anemia,  and  the  like.  All 
children  lacking  evidences  of  vaccination,  or  who  have  or  are  suspected  of 
having  defects,  are  brought  before  the  school  physician  at  his  morning  visit, 
which  lasts  from  one  to  three  or  more  hours  each  school  day  until  all  the  exam¬ 
inations  are  completed. 

The  examinations  are  confined  practically  to  physical  inspection — head, 
eyes,  ears,  nose,  throat,  neck,  and  extremities.  Only  exceptionally  do  they  go 
further  and  embrace  examination  of  the  chest  for  diseases  of  the  heart  and 
lungs.  Where  acute  febrile  disease  is  evident  or  suspected,  the  temperature 
and  the  pulse-rate  may  be  taken.  No  routine  examination  is  made  for  the  acute 
diseases  of  childhood.  No  medical  treatment  is  prescribed  or  given  by  the 
physicians.  Exclusion  is  ordered  for  lack  of  evidence  of  successful  vaccination, 
for  vermin,  impetigo,  sore  throat,  and  the  usual  contactive  diseases  of  childhood 
when  discovered.  Cards  recording  the  cause  for  exclusion  are  sent  to  the 
parents,  and  the  health  department  is  notified  of  cases  falling  under  the  list  of 
reportable  diseases.  In  cases  of  defects  or  diseases  of  the  eyes,  ears,  nose,  tonsils, 
and  teeth,  and  of  evident  anemia  or  suspected  tuberculosis,  and  the  like,  the 
parents  are  advised  to  consult  the  family  physician  or  an  appropriate  dispensary 
service.  In  a  large  proportion  of  cases  of  the  latter  group,  nothing  is  done 
unless  the  children  are  followed  up  in  their  homes  by  the  nurse,  and  the  mother 
is  besought  to  seek  medical  advice.  Children  with  defects  of  eyes,  ears,  nose, 
throat,  and  teeth  are  often  taken  in  parties  by  the  nurse  to  the  dispensaries  for 
examination  and  treatment.  In  many  cases  of  children  infested  by  vermin, 
usually  head  and  body  lice  and  scabies,  the  nurse  applies  the  appropriate  reme¬ 
dies  in  the  home,  often,  of  course,  finding  it  necessary  to  treat  the  whole  family. 
In  1917  the  number  of  school  nurses  was  doubled. 

The  physicians  have  returned  each  year  reports  with  lists  of  the  numbers  of 
pupils  examined  and  the  number  of  defective  and  those  instances  in  which 
each  of  the  more  usual  defects  were  found.  These  data  are  sometimes  given 
in  some  districts  for  each  separate  school.  The  percentage  of  defects  found 
vary  widely  in  the  various  schools.  Taking  Dr.  H.  Warren  Buckler’s  report  for 
1908  as  an  example  of  20  schools,  the  lowest  and  highest  percentages  of  defec- 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


169 


tives  were  22.9  and  49  respectively.  Under  the  various  headings,  the  highest 
and  lowest  percentages  were  as  shown  in  table  7. 

To  take  another  year  as  an  example,  tables  are  given  in  the  report  of  1911 


Table  7. 


Defects. 

Highest 

percentage. 

Lowest 

percentage. 

Eye  and  ear . 

12.3 

3.0 

Nose  and  throat . 

24.7 

7.0 

Communicable  parasitic  diseases . 

20.3 

1.0 

Filth  . 

8.1 

0.0 

Malnutrition  . 

9.0 

0.0 

Imperfect  teeth  . 

36.9 

6.5 

Unvaccinated  . 

2.4 

0.0 

showing  the  total  number  of  pupils  examined  in  the  public  and  parochial  schools 
and  the  number  of  instances  in  w7hich  various  “  defects  ”  were  recorded. 


Table  8. — Number  and  'proportion  of  children  with  defects  and  diseases,  compiled  from 
the  Annual  Report  of  the  Health  Department  of  Baltimore,  1911. 


Affection. 

• 

White. 

Percentage 

affected. 

Colored. 

Percentage 

affected. 

Total. 

Percentage 

affected. 

No.  of  pupils . 

47,401 

•  •  •  • 

5,318 

•  •  •  • 

52,719 

•  •  •  • 

Sick  and  disordered,  all  causes . 

24,509 

51.71 

2,378 

44.72 

26,887 

51.00 

No.  unvaccinated  . 

2,392 

5.05 

210 

3.95 

2,602 

4.94 

Pediculosis  . 

4,377 

9.23 

103 

1.94 

4,480 

8.50 

Adenoids  . 

3,435 

7.25 

319 

6.00 

3,754 

7.12 

Rhinitis  . 

980 

2.07 

128 

2.41 

1,108 

2.10 

Enlarged  tonsils . 

4,761 

10.04 

522 

9.82 

5,283 

10.02 

Eye  strain  . 

1,752 

3.70 

210 

3.95 

1,962 

3.72 

Total  eye  defects . 

3,045 

6.42 

347 

6.53 

3,392 

6.43 

Ear  defects  . 

263 

0.55 

21 

0.39 

284 

0.54 

Teeth  defects  . 

7,056 

14.89 

794 

14.93 

7,850 

14.89 

Adenitis  (cervical  lymph-glands  enlarged) 

797 

1.68 

103 

1.94 

900 

1.71 

Tuberculosis,  various  organs . 

64 

0.14 

20 

0.38 

84 

0.16 

Mentally  defective . 

254 

0.54 

21 

0.39 

275 

0.52 

Debility  . 

617 

1.30 

49 

0.92 

666 

1.26 

Table  8  must  be  interpreted  with  care.  It  is  evident  that  some  pupils  have 
more  than  one  “  defect.”  The  high  proportion  of  cases  of  pediculosis,  the 
greater  number  of  which  occurring  among  whites,  was  due  to  the  fact  that  in 
some  of  the  white  schools  many  or  most  of  the  children  were  so  affected,  while 
in  most  of  the  white  schools  none  of  the  pupils  were  infested.  The  text  of  the 
reports  shows  that  only  in  certain  schools  were  there  instances  of  pediculosis, 
and  from  these  it  was  difficult  to  eradicate  it,  owing  to  the  habits  of  the  people. 
Pediculosis  among  the  whites,  except  for  accidental  infestion  arising  in  school 


170  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

contact,  was  confined  to  certain  races  of  more  recent  immigration.  In  a  few 
years,  through  the  effective  work  of  the  school  nurses,  the  schools  were  practi¬ 
cally  rid  of  this  affection.  For  the  other  defects,  these  figures,  except  for  the 
category  of  mental  deficiency,  probably  give  an  accurate  picture  of  their  dis¬ 
tribution  in  the  population  under  consideration.  Some  of  the  most  common 
defects  noted  occur  together  frequently,  such  as  enlarged  tonsils,  adenoids, 
rhinitis,  and  enlarged  cervical  lymph-glands.  These  perhaps  might  be  grouped 
together  without  serious  error  as  affecting  between  5  and  7  per  cent  of  the  whole 
number  of  pupils.  The  most  important  categories  are  the  large  proportion  of 
cases  of  eye-strain  and  other  abnormalities  of  the  eyes  (3.72  per  cent  and  6.43 
per  cent,  respectively)  and  of  children  with  defective  permanent  teeth  (14.89 
per  cent).  Upon  these,  pediculosis,  and  vaccination,  the  inspectors  and  nurses 
very  properly  concentrate  their  attention,  and  under  very  considerable  diffi¬ 
culties,  at  first  interposed  on  the  part  of  the  parents,  the  children,  and  even 
some  of  the  teachers,  great  progress  has  been  made.  This  advance  has  been  less 
satisfactory  in  connection  with  teeth,  because  of  lack  of  a  sufficient  number  of 
dental  clinics  in  the  schools.  It  is  probable  that  many  children  whose  parents 
were  able  to  afford  it  have  been  induced  to  consult  dentists  in  private  practice, 
but  so  great  was  the  need  for  treatment  among  children  of  the  poorer  classes 
that  the  free  dental  clinics  in  connection  with  the  dental  schools  of  the  city 
are  still  unable  to  cope  with  the  situation.  A  few  dental  clinics  have  been  set 
up  in  some  of  the  schools  where  most  needed,  apparatus  and  services  being 
donated  by  dentists,  and  money  contributed  by  parents’  associations  and  other 
organizations.  This  important  field  of  child  hygiene  has,  however,  hardly  been 
touched. 

In  regard  to  adenoids  and  enlarged  tonsils,  the  school  inspectors,  all  of  whom 
are  experienced  practitioners  of  medicine,  have  sustained  a  judicious  attitude, 
advocating  removal  only  in  those  cases  in  which  it  was  reasonable  to  think  that 
improvement  would  ensue.  While  the  inspectors  determined  which  cases  should 
seek  medical  or  surgical  attention,  the  ultimate  decision  lay  with  the  parents 
and  the  family  or  the  dispensary  physician.  The  small  number  of  cases  of  evi¬ 
dent  tuberculosis  enumerated  do  not  represent  the  true  number  of  cases  of  clini¬ 
cal  tuberculosis  among  the  Baltimore  school  children,  for  the  examinations 
given  are  far  too  incomplete  to  lead  to  the  discovery  of  any  except  the  most  ob¬ 
vious  cases.  Nor  does  the  group  of  mentally  defective  give  a  true  picture  of  the 
situation.  The  cases  enumerated  probably  include  only  the  evident  idiots  and 
a  certain  proportion  of  the  more  backward  children,  for  neither  the  inspectors 
nor  the  school-teachers  applied  the  more  refined  methods  of  diagnosis.  The 
small  proportion  of  unvaccinated  children  (4.94  per  cent)  speaks  well  for  the 
success  of  the  efforts  of  the  health  department  to  enforce  the  vaccination  ordi¬ 
nance  in  late  years.  The  item  “  debility  ”  stands  for  malnutrition  or  under¬ 
nourishment,  and,  according  to  the  reports  of  the  inspectors,  this  is  very 
unevenly  distributed  among  the  schools  and  is  largely  confined  to  the  children 
of  recent  immigrants  of  certain  race-stocks.  According  to  the  reports  of  the 
inspectors  and  nurses,  this  condition  among  the  children  of  the  public  and 
parochial  schools  is  due  much  more  to  lack  of  proper  kinds  and  choice  of  foods 
and  to  methods  of  their  preparation  than  to  lack  of  ability  of  the  parents  to 
purchase  food.  It  is  of  interest  that,  under  the  most  important  categories,  the 


PUBLIC  HEALTH  ADMINISTRATION  OF  BALTIMORE 


171 


negroes  compare  not  unfavorably  with  the  whites,  and  on  the  whole  show  a 
smaller  proportion  of  defectives. 

During  the  year  under  review  there  were  brought  to  the  attention  of  the 
inspectors  and  nurses  only  11  cases  of  the  ordinary  communicable  diseases  of 
childhood :  Mumps  8  cases,  and  diphtheria,  measles,  and  chicken-pox  1  case  each. 
This  emphasizes  the  fact  that  the  inspection  is  discontinuous,  the  relatively 
small  inspection  forces,  owing  to  lack  of  time,  ordinarily  visiting  a  particular 
school  but  twice  a  year — the  second  inspection  to  examine  children  absent  at 
the  first.  Only  in  exceptional  instances  of  considerable  outbreaks  of  diphtheria, 
scarlet  fever,  measles,  mumps,  or  chicken-pox  have  the  school  inspectors  been 
detailed  thoroughly  to  investigate  the  children  in  particular  schools  for  cases 
of  such  diseases.  In  other  words,  the  school-inspection  system  was  not  designed, 
nor  was  it  ever  adequate,  for  the  purpose  of  seeking  to  prevent  or  control  out¬ 
breaks  of  “  zymotic  ”  disease. 

The  school-inspection  system  is  quite  independent  of  the  school  board  and 
no  reports  are  made  to  it.  The  board  of  estimates  appropriates  money  aunually 
to  the  commissioner  of  health  for  salaries  for  so  many  school  inspectors  or 
school  nurses,  and  the  commissioner  of  health,  under  his  general  powers,  insti¬ 
tutes  a  system  of  inspection  in  the  schools.  The  school  board,  its  officers,  and 
teachers  happen  to  be  in  sympathy  with  the  movement  and  actively  cooperate, 
but  whatever  their  attitude,  they  could  at  most  interfere  only  with  the  smooth¬ 
ness  of  the  work.  The  inspection  system  has  been  of  very  great  value,  and  that 
it  has  not  been  of  greater  value  is  due  to  the  fact  that  means  have  not  been 
supplied  to  develop  the  leads  it  has  disclosed.  If  its  only  accomplishment  had 
been  the  supervision  of  vaccination  enforcement  it  would  have  paid  for  itself 
many  times.  In  addition,  it  has  resulted  in  ridding  the  school  children  of  lice 
and  has  caused  great  numbers  of  children  to  have  their  eyes,  teeth,  throats,  and 
noses  properly  cared  for.  Indirectly,  it  has  resulted  in  cleaner  and  better  venti¬ 
lated  and  lighted  schools,  and  the  instruction  of  both  teachers  and  children  in 
the  elements  of  personal  hygiene.  It  has  gathered  valuable  information,  on 
which  could  be  based  a  system  of  inspection  and  relief  meeting  the  demands  of 
the  local  situation. 


THE  BUREAU  OF  NURSING. 

The  use  of  the  trained  nurse  in  the  health  department  developed  in  a  hap¬ 
hazard  manner  from  small  beginnings.  One  nurse  was  appointed  in  1905,  in 
connection  with  the  inspection  of  school-children.  The  number  was  increased  to 
5  in  1906,  to  10  in  1917  and  to  18  in  1920.  A  division  of  tuberculosis  nurses 
was  created  in  1910,  with  14  field  nurses  and  a  superintendent.  This  number 
was  raised  to  16  in  1912,  to  20  in  1917  and  to  26  in  1920.  Nurses  devoted  their 
whole  time  to  this  work. 

In  1917,  3  extra  nurses  were  detailed  for  special  services  in  connection  with 
cases  of  diphtheria,  scarlet  and  typhoid  fevers,  and  whooping-cough,  and  in 
1919  a  fourth  corps  of  nurses  was  appointed  to  services  in  the  bureau  of  mater¬ 
nity  and  infant  welfare.  In  1918,  the  disciplinary  and  field  work  of  the  whole 
nursing  force  was  placed  in  charge  of  a  superintendent  of  nurses,  and  in  1920 
a  separate  bureau  of  nurses  was  established  with  a  total  force  of  83  nurses. 

12 


172  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


The  superintendent  of  nurses  has  always  directed  the  nursing  work  in  con¬ 
nection  with  tuberculosis,  but  the  other  nurses  work  under  the  direction  of  and 
render  reports  to  the  medical  officials  of  the  various  services  to  which  they  are 
assigned. 


BUREAU  OF  COMMUNICABLE  DISEASES. 

This  bureau,  established  in  1917,  has  charge  of  the  activities  of  the  depart¬ 
ment  in  respect  to  the  supervision  and  restriction  of  persons  with  communicable 
diseases,  except  tuberculosis.  The  chief  of  the  bureau  is  the  epidemiologist  of 
the  department,  receives  the  reports,  histories,  and  other  records  of  cases  and 
directs  the  work  of  the  health  wardens  and  corps  of  nurses,  particularly  in 
regard  to  the  isolation,  hospitalization  and  release  of  cases  and  of  contacts. 
His  services  as  diagnostician  are  available  in  doubtful  cases.  Before  the  estab¬ 
lishment  of  this  bureau  these  activities  were  supervised  by  the  single  assistant 
commissioner  of  health  as  and  when  he  could  find  time  from  other  duties. 

BUREAU  OF  CHILD  WELFARE. 

This  bureau  was  established  in  1919,  and  as  its  work  is  almost  entirely  new, 
it  can  have  exercised  no  significant  influence  upon  morbidity  and  mortality 
during  the  period  covered  in  this  work.  Besides  the  oversight  of  midwives, 
foundling  and  orphan  asylums,  boarding  homes,  and  other  institutions  caring 
for  young  children,  the  bureau  conducts  2  obstetrical  and  4  prenatal  chinics  and 
a  day  nursery.  An  important  feature  of  the  work  is  a  complete  history  of 
each  baby. 

MISCELLANEOUS  SERVICES. 

For  many  years  the  city  morgue,  potter's  field,  and  the  city  post  mortem 
physicians  have  been  under  the  health  department.  The  department  has  from 
the  beginning  supervised  the  destruction  of  clothes,  bedding,  and  other  effects 
of  individuals  with  small-pox.  Since  1905  a  separate  service  has  been  conducted 
for  the  fumigation  with  formaldehyde  gas  of  houses  harboring  cases  of  pul¬ 
monary  tuberculosis,  small-pox,  diphtheria,  and  scarlet  and  typhus  fevers,  and 
for  sterilization  by  steam  or  the  destruction  by  fire,  when  desired,  of  articles  of 
clothing  and  bedding  after  recovery  or  death  of  individuals  with  these  diseases. 
At  various  times  there  have  been  sanitary  inspectors  for  general  nuisances  and 
for  tenements  and  boarding-houses. 


PART  IV.— POPULATION  AND  STATISTICAL  DATA. 

Chapter  VIII. 


1.  Population:  Rate  of  growth;  Racial  composition;  Distribution  by 
numbers,  sex,  and  race.  (Tables  9  to  13,  graph  1.) 

2.  Natality:  Living  births;  still-births.  (Tables  10  to  15,  124,  126,  132.) 


POPULATION. 

Since  the  questions  of  the  growth  and  racial  composition  of  the  population 
involve  factors  that  affected  the  sanitary  conditions  and- the  variations  in  the 
resistance  and  susceptibility  of  the  inhabitants  to  certain  diseases,  and,  in 


Table  9. — Percentage  of  increase  of  total,  white,  and  colored  'populations  and  proportion  of 
white  and  colored  populations  to  the  total  population,  from  1730  to  1920,  inclusive. 


Year. 

Total  popula¬ 
tion. 

White  population. 

Colored  population. 

Census  count. 

Percentage  of 
increase. 

Census  count. 

Percentage  of 
increase. 

Percentage  to 
total  popula¬ 
tion. 

Total. 

Free. 

Slave. 

Census 

count. 

Percentage 
of  increase. 

Percentage 
to  total 
population. 

Census 

count. 

t 

Percentage 
of  increase. 

Percentage 
to  total 
population. 

Census 

count. 

Percentage 

of  increase. 

Percentage 

to  total 
population. 

1730 

43 

•  ••••• 

1762 

200 

365. ii 

•  ••••• 

...... 

...... 

...... 

...... 

...... 

...... 

...... 

...... 

...... 

...... 

1775 

6934 

2867.00 

•  ••••• 

...... 

...... 

...... 

...... 

...... 

... 

....  .  . 

. 

...... 

. 

. 

1776 

6765 

13.84 

1790 

13503 

99.90 

11925 

88.31 

1578 

11.69 

323 

2.39 

1255 

9.29 

1800 

26514 

96.36 

20900 

75.26 

78.83 

5614 

255.77 

21.17 

2771 

757.89 

10.45 

2843 

126.63 

10.72 

1810 

46555 

75.59 

36212 

73.26 

77.78 

10343 

84.24 

22.22 

5671 

104.66 

12.18 

4672 

64.33 

10.04 

1820 

62738 

34.76 

48055 

32.70 

76.60 

14683 

41.96 

23.40 

10326 

82.08 

16.46 

4367 

*6.74 

6.94 

1830 

80625 

28.61 

61714 

28.42 

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*  Decrease. 


consequence,  have  exercised  imporant  influences  upon  the  morbidity  and  mor¬ 
tality  rates,  it  is  necessary  to  consider  them  in  some  detail.  The  essential  data 
concerning  the  rate  of  growth  and  the  proportion  of  whites  and  negroes  to  the 
total  population  are  presented  in  table  9  compiled  from  the  figures  of  Quinan, 
from  1730  to  1776,  and  from  figures  obtained  from  the  reports  or  from  the 
office  of  the  Bureau  of  the  Census,  from  1790  to  1920.  At  the  date  of  the  first 
census  (1790),  Baltimore  was  among  the  five  cities  of  the  country  with  over 
8,000  population,  the  others  being  Philadelphia  and  suburbs  (42,444),  New 
York  (33,131),  Boston  (18,038),  and  Charleston  (16,359). 

RATE  OF  POPULATION  INCREASE. 

The  history  of  the  growth  of  population  in  Baltimore  is  epitomized  in 
table  9.  In  regard  to  the  whole  population,  it  is  evident  that  immigration 

173 


Table  10. — The  papulations  specific  for  certain  age-groups,  the  percentages  of  increase  of  the  latter  over  those  of  the  preceding  decennium; 
and  the  percentages  of  these  age  distributions  of  the  respective  total  populations,  for  the  census  years,  1830  to  1920  inclusive .* 


174 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


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Table  10. — The  populations  specific  for  certain  age-groups,  percentage  of  increase,  etc. t — Continued. 


POPULATION  AND  STATISTICAL  DATA 


175 


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*  Percentage  of  decrease. 

t  The  population  figures  in  brackets  for  1880  and  1890  represent  graduations  from  the  5-year  age-groupings  of  the  Bureau  of  the  Census  for 
those  years. 


176  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

played  a  predominant  role  in  the  rate  of  increase,  which,  until  1890,  far  ex¬ 
ceeded  any  rate  possible  by  the  natural  means  of  excess  of  births  over  deaths. 
With  an  average  annual  rate  of  increase  of  over  16  per  cent  between  1730  and 
1752,  from  the  latter  date  until  1810,  the  rate  of  growth  was  that  of  a  boom 
town — 124  per  cent  annually  from  1752  to  1775,  and  9  per  cent  from  1775  to 
1810.  During  the  three  decades  1810  to  1840,  the  average  annual  rate  of 
increase  was  less  than  3  per  cent.  There  was  a  sudden  jump  to  6.5  per  cent 
between  1840  and  1850,  followed  by  a  descent  to  an  average  annual  rate  of 
about  2.7  per  cent  for  the  40  years  between  1850  and  1890.  During  the  last 
three  decades  the  rate  of  increase  was  much  reduced.  The  sharp  rise  in  the 
rate  of  increase  between  1880  and  1890  was  associated  with  a  considerable 
annexation  in  1888,  the  only  extension  of  the  city’s  boundaries  since  1816.  It  is 
probable  that  but  for  the  influx  of  population  in  1916-1918,  due  to  conditions 
arising  out  of  the  Great  War  and  the  third  great  annexation  in  1919,  the  annual 
rate  of  increase  between  1900  and  1920  would  have  followed  the  general 
average  of  less  than  1  per  cent,  which  obtained  in  the  previous  decade,  when 
for  the  first  time  in  the  history  of  Baltimore  the  rate  of  growth  approached  the 
natural  rate  of  increase,  or  that  regulated  by  the  increase  of  births  over  deaths. 

In  table  10  is  given  the  numerical  distribution  by  certain  age-groups  for 
the  total  population  for  the  census  years  1830  to  1920,  inclusive,  together  with 
the  percentage  borne  by  each  age-group  to  the  respective  totals,  the  percentage 
of  increase  in  each  age-group  from  one  decennium  to  the  next,  and  the  percent¬ 
age  of  changes  in  the  ratios,  whether  decline  or  increase,  of  population  dis¬ 
tributed  by  age  to  total  population  from  1850  to  1920.  For  the  years  1850, 
1860,  1900,  1910,  and  1920  the  figures  for  the  various  age-groupings  are  copied 
directly  from  the  publications  of  the  Bureau  of  the  Census.  For  the  other  years 
it  has  been  necessary  to  resort  to  graduation  to  obtain  comparable  figures  for 
certain  of  the  age-groupings.  For  1830  and  1840  it  was  necessary  to  graduate 
the  figures  for  the  negro  moiety  of  the  population,  and  for  1880  and  1890  the 
census  figures  given  for  5-year  groupings  were  graduated  to  10-year  groupings. 
The  figures  for  the  age-groupings  for  1870  were  graduated  throughout.  These 
data  may  be  regarded  as  reasonably  correct  for  measurement  of  changes  in  these 
age-groupings  and  for  the  calculation  of  morbidity  and  mortality  rates  specific 
for  age.  Of  particular  importance  are  the  data  concerning  the  proportional 
distribution  of  the  population  below  the  various  decades  of  life  for  the  decennial 
or  census  years.  Attention  is  directed  particularly  to  the  ratios  of  decrease  and 
of  increase  in  the  different  age-groups  between  1850  and  1920  which  are  given 
in  the  last  two  columns  of  the  table.  These  changes,  while  considerable  when 
measured  over  this  span  of  70  years,  were  in  the  main  gradual  from  one  decen¬ 
nium  to  the  next.  Their  important  bearing  upon  the  interpretation  of  crude 
mortality  rates  from  all  causes  and  upon  morbidity  and  mortality  rates  from 
specific  diseases  and  groups  of  diseases  is  obvious. 

Populations  specific  for  the  same  age-groupings  by  color  and  sex  for  1910 
and  1920  are  given  in  table  11. 

In  table  12,  graph  1,  are  presented  the  figures  for  the  population  at  all  ages, 
for  total  population,  and  for  color  and  sex  which  will  be  used  in  this  work  for 
the  calculation  of  all  natality,  morbidity,  and  mortality  rates  except  those 
specific  for  age.  These  populations  were  estimated  by  Dr.  John  Bice  Miner  by 


POPULATION  AND  STATISTICAL  DATA 


177 


fitting  curves  by  the  method  of  least  squares  to  the  populations  of  Baltimore  at 
the  several  censuses.  In  order  to  allow  for  the  discontinuity  due  to  the  annexa¬ 
tion  of  1888,  the  following  procedure  was  adopted  :  Before  1888  the  population 


Table  11. — Populations  specific  for  certain  age  groupings  by  color  and  sex  for  1910  and  1920. 


Age  period. 

1910 

1920 

White. 

Colored. 

White. 

Colored. 

Total. 

Male. 

Fein. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

Total. 

Male.  Fem. 

Under  1  year . 

Between  1  and  2  years 

2  to  4  years . 

5  to  9  years . 

0  to  9  years . 

10  to  19  years . 

20  to  29  years . 

SO  to  39  years . 

40  to  49  years . 

50  to  59  years . 

60  to  69  years . 

70  to  79  years . 

80  years  and  over.... 

Total  . 

8891 

8485 

27980 

43199 

88555 

88989 

92404 

72960 

57195 

39054 

21917 

9457 

2375 

4489 

4384 

14062 

21679 

44614 

42838 

44456 

35574 

27564 

18883 

9883 

3938 

858 

4402 

4101 

13918 

21520 

43941 

46151 

47948 

37386 

29631 

20171 

12034 

5519 

1517 

1348 

1127 

4155 

6418 

13048 

13771 

2060 

15807 

11395 

6063 

2888 

996 

296 

685 

557 

2012 

3060 

6314 

5850 

9044 

7650 

6655 

2960 

1320 

403 

93 

663 

570 

2143 

3358 

6734 

7921 

11576 

8157 

5740 

3103 

1568 

693 

203 

12884 

■  48097 

56423 

117404 

107776 

19068 

100573 

76767 

54705 

32543 

13058 

3126 

6600 

24145 

28582 

59327 

52818 

58780 

50434 

38202 

26684 

15306 

5597 

1123 

6284 

23952 

27841 

58077 

54958 

60288 

50139 

38565 

28021 

17237 

7461 

2003 

1968 

6409 

8069 

16444 

15954 

25829 

21820 

15575 

7858 

3465 

1356 

354 

957 

3113 

3861 

7931 

7069 

12187 

11053 

8285 

4245 

1713 

605 

134 

1011 

3294 

4208 

8513 

8885 

13642 

10767 

7290 

3613 

1752 

751 

220 

472906 

228608 

244298 

84884 

39289 

45595 

625020 

308271 

316749 

108655 

53222 

55438 

figures  were  taken  from  a  logarithmic  curve  which  fitted  that  portion  of  the 
census  figures  most  closely,  whereas  the  figures  for  the  period  since  1888  were 
taken  from  an  autocatalytic  curve  (44).  In  this  way  the  sudden  increase  in 
the  population  at  the  annexation  was  satisfactorily  represented. 


KHZ  20  30  40  60  60  70  60  90  1900  10  20 

YEARS 


Graph  1  (from  table  12).  Estimated  annual  populations,  in  thousands,  for 
males  and  females,  white  and  colored,  for  Baltimore  from  1812  to  1920, 
inclusive. 


178  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


Table  12. — Estimated  population  of  Baltimore  City,  as  of  July  1  of  each  year,  from  1812 

to  1920,  inclusive. 


Year. 

Total. 

White. 

I 

Colored. 

Total. 

Male 

Fem. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

1812  . 

1 

40937 

20388 

20549 

30076 

15997 

14079 

10861 

4391 

6470 

1813  . 

42799 

21224 

21575 

31649 

16748 

14901 

11150 

4476 

6674 

1814  . 

44731 

22092 

22639 

33288 

17529 

15759 

11443 

4563 

6880 

1815  . 

46734 

22992 

23742 

35000 

18343 

16657 

11734 

4649 

7085 

1816  . 

48813 

23927 

24886 

36780 

19189 

17591 

12033 

4738 

7295 

1817  . 

50962 

24897 

26065 

38629 

20068 

18561 

12333 

4829 

7504 

1818  . 

53189 

25902 

27287 

40549 

20979 

19570 

12640 

4923 

7717 

1819  . 

55486 

26940 

28546 

42535 

21921 

20614 

12951 

5019 

7932 

1820  . 

57859 

28014 

29845 

44590 

22895 

21695 

13269 

5119 

8150 

1821  . 

60305 

29123 

31182 

46713 

23901 

22812 

13592 

5222 

8370 

1822  . 

62825 

30266 

32559 

48902 

24938 

23964 

13923 

5328 

8595 

1823  . 

65418 

31446 

33972 

51158 

26007 

25151 

14260 

5439 

8821 

1824  . 

68088 

32662 

35426 

53483 

27109 

26374 

14605 

5553 

9052 

1825  . 

70834 

33915 

36919 

55875 

28242 

27633 

14959 

5673 

9286 

1826  . 

73651 

35202 

38449 

58332 

29406 

28926 

15319 

5796 

9523 

1827  . 

76544 

36525 

40019 

60854 

30600 

30254 

15690 

5925 

9765 

1828  . 

79513 

37887 

41626 

63445 

31829 

31616 

16068 

6058 

10010 

1829  . 

82555 

39284 

43271 

66099 

33087 

33012 

16456 

6197 

10259 

1830  . 

85674 

40716 

44958 

68821 

34377 

34444 

16853 

6339 

10514 

1831  . 

88867 

42187 

46680 

71607 

35698 

35909 

17260 

6489 

10771 

1832  . 

92136 

43694 

48442 

74458 

37050 

37408 

17678 

6644 

11034 

1833  . 

95479 

45238 

50241 

77375 

38434 

38941 

18104 

6804 

11300 

1834  . 

98901 

46820 

52081 

80357 

39849 

40508 

18544 

6971 

11573 

1835  . 

102395 

48439 

53956 

83403 

41295 

42108 

18992 

7144 

11848 

1836  . 

105966 

50094 

55872 

86515 

42772 

43743' 

19451 

7322 

12129 

1837  . 

109612 

51788 

57824 

89691 

44281 

45410 

19921 

7507 

12414 

1838  . 

113335 

53519 

59816 

92932 

45821 

47111 

20403 

7698 

12705 

1839  . 

117132 

55286 

61846 

96237 

47391 

48846 

20895 

7895 

13000 

1840  . 

121008 

57093 

63915 

99608 

48994 

50614 

21400 

8099 

13301 

1841  . 

124956 

58936 

66020 

103041 

50627 

52414 

21915 

8309 

13606 

1842  . 

128983 

60817 

68166 

106539 

52291 

54248 

22444 

8526 

13918 

1843  . 

133084 

62737 

70347 

110102 

53987 

56115 

22982 

8750 

14232 

1844  . 

137264 

64693 

72571 

113729 

55713 

58016 

23535 

8980 

14555 

1845  . 

141518 

66689 

74829 

117420 

57471 

59949 

24098 

9218 

14880 

1846  . 

145848 

68720 

77128 

121174 

59259 

61915 

24674 

9461 

15213 

1847  . 

150252 

70790 

79462 

124991 

61078 

63913 

25261 

9712 

15549 

1848  . 

154737 

72900 

81837 

128874 

62929 

65945 

25863 

9971 

15892 

1849  . 

159294 

75046 

84248 

132820 

64811 

68009 

26474 

10235 

16239 

1850  . 

163930 

77231 

86699 

136829 

66723 

70106 

27101 

10508 

16593 

1851  . 

168640 

79454 

89186 

140902 

68667 

72235 

27738 

10787 

16951 

1852  . 

173427 

81715 

91712 

145037 

70641 

74396 

28390 

11074 

17316 

1853  . 

178293 

84016 

94277 

149239 

72648 

76591 

29054 

11368 

17686 

1854  . 

183233 

86353 

96880 

153502 

74684 

78818 

29371 

11669 

18062 

1855  . 

188251 

88730 

99521 

157829 

76751 

81078 

30422 

11979 

18443 

1856  . 

193344 

91145 

102199 

162219 

78850 

83369 

31125 

12295 

18830 

1857  . 

198514 

93598 

104916 

166672 

80979 

85693 

31842 

12619 

19223 

1858  . 

203761 

96089 

107672 

171188 

83138 

88050 

32573 

12951 

19622 

1859  . 

209083 

98620 

110463 

175768 

85330 

90438 

33315 

13290 

20025 

1860  . 

214484 

101188 

113296 

180411 

87552 

92859 

34073 

13636 

20437 

1861  . 

219957 

103794 

116163 

185115 

89804 

95311 

34842 

13990 

20852 

1862  . 

225511 

106439 

119072 

189884 

92087 

97797 

35627 

14352 

21275 

1863  . 

231140 

109124 

122016 

194716 

94402 

100314 

36424 

14722 

21702 

1864  . 

236845 

111846 

124999 

199611 

96747 

102864 

37234 

15099 

22135 

1865  . 

242629 

114608 

128021 

204570 

99124 

105446 

38059 

15484 

22575 

1866  . 

248487 

117407 

131080 

209589 

101530 

108059 

38898 

15877 

23021 

POPULATION  AND  STATISTICAL  DATA 


179 


Table  12. — Estimated  population  of  Baltimore  City  as  of  July  1  of  each  year,  from  1812 

to  1920,  inclusive — Continued. 


Year. 

Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

1867  . 

254422 

1 

120246 

134176 

214672 

103968 

110704 

39750 

16278 

23472 

1868  . 

260435 

123122 

137313 

219820 

106437 

113383 

40615 

16685 

23930 

1869  . 

266523 

126039 

140484 

225029 

108937 

116092 

41494 

17102 

24392 

1870  . 

272690 

128993 

143697 

230301 

111467 

118834 

42389 

17526 

24863 

1871  . 

278932 

131987 

146945 

235636 

114028 

121608 

43296 

17959 

25337 

1872  . 

285251 

135018 

150233 

241034 

116620 

124414 

44217 

18398 

25819 

1873  . 

291646 

138089 

153557 

246493 

119242 

127251 

45153 

18847 

26306 

1874  . 

298121 

141200 

156921 

252016 

121896 

130120 

46105 

19304 

26801 

1875  . 

304670 

144348 

160322 

257603 

124581 

133022 

47067 

19767 

27300 

1876  . 

311297 

147536 

163761 

263251 

127296 

135955 

48046 

20240 

27806 

1877  . 

318000 

150762 

167238 

268962 

130042 

138920 

49038 

20720 

28318 

1878  . 

324783 

154028 

170755 

274737 

132819 

141918 

50046 

21209 

28837 

1879  . 

331639 

157333 

174306 

280573 

135627 

144946 

51066 

21706 

29360 

1880  . 

338573 

160675 

177898 

286472 

138465 

148007 

52101 

22210 

29891 

1881  . 

345584 

164057 

181527 

292434 

141334 

151100 

53150 

22723 

30427 

1882  . 

352674 

167479 

185195 

298459 

144235 

154224 

54215 

23244 

30971 

1883  . 

359838 

170938 

188900 

304545 

147165 

157380 

55293 

23773 

31520 

1884  . 

367079 

174437 

192642 

310693 

150126 

160567 

56386 

24311 

32075 

1885  . 

374396 

177974 

196422 

316904 

153118 

163786 

57492 

24856 

32636 

1886  . 

381793 

181551 

200242 

323178 

156141 

167037 

58615 

25410 

33205 

1887  . 

389265 

185167 

204098 

329515 

159195 

170320 

59750 

25972 

33778 

1888  . 

419572 

198102 

221470 

355859 

170192 

185667 

63713 

27910 

35803 

1889  . 

427078 

201823 

225255 

362225 

173370 

188855 

64853 

28453 

36400 

1890  . 

434560 

205547 

229013 

368560 

176547 

192013 

66000 

29000 

37000 

1891  . 

442011 

209271 

232740 

374858 

179719 

195139 

67153 

29552 

37601 

1892  . 

449429 

212994 

236435 

381116 

182886 

198230 

68313 

30108 

38205 

1893  . 

456808 

216714 

240094 

387329 

186045 

201284 

69479 

30669 

38810 

1894  . 

464092 

220426 

243666 

393492 

189193 

204299 

70600 

31233 

39367 

1895  . 

471426 

224129 

247297 

399602 

192328 

207274 

71824 

31801 

40023 

1896  . 

478657 

227822 

250835 

405654 

195449 

210205 

73003 

32373 

40630 

1897  . 

485832 

231501 

254331 

411646 

198554 

213092 

74186 

32947 

41239 

1898  . 

492945 

235164 

257781 

417573 

201639 

215934 

75372 

33525 

41847 

1899  . 

500141 

238810 

261331 

423580 

204705 

218975 

76561 

34105 

42456 

1900  . 

506970 

242435 

264535 

429218 

207747 

221471 

77752 

34688 

43064 

1901  . 

513875 

246038 

267832 

434930 

210765 

224165 

78945 

35273 

43672 

1902  . 

520706 

249619 

271087 

440566 

213758 

226808 

80140 

35861 

44279 

1903  . 

527456 

253172 

274284 

446121 

216722 

229399 

81335 

36450 

44885 

1904  . 

534122 

256697 

277425 

451593 

219657 

231936 

82529 

37040 

45489 

1905  . 

540705 

260193 

280512 

456981 

222561 

234420 

83724 

37632 

46092 

1906  . 

547212 

263667 

283545 

462284 

225433 

236851 

84928 

38234 

46694 

1907  . 

553609 

267090 

286519 

467497 

228271 

239226 

86112 

38819 

47293 

1908  . 

559924 

270487 

289437 

472620 

231073 

241547 

87304 

39414 

47890 

1909  . 

566145 

273848 

292297 

477653 

233840 

243813 

88492 

40008 

48484 

1910  . 

572269 

277170 

295099 

482591 

236568 

246023 

89678 

40602 

49076 

1911  . 

578297 

280455 

297842 

487436 

239258 

248178 

90861 

41197 

49664 

1912  . 

584227 

283698 

300529 

492187 

241908 

250279 

92040 

41790 

50250 

1913  . 

590056 

286900 

303156 

496841 

244517 

252324 

93215 

42383 

50832 

1914  . 

595785 

290060 

305725 

501400 

247085 

254315 

94385 

42975 

51410 

1915  . 

601413 

293176 

308237 

505863 

249611 

256252 

95550 

43565 

51985 

1916  . 

606937 

296247 

310690 

510228 

252093 

258135 

96709 

44154 

52555 

1917  . 

612360 

299273 

313087 

514497 

254532 

259965 

97863 

44741 

53122 

1918  . 

617680 

302254 

315426 

518671 

256928 

261743 

99009 

45326 

53683 

1919  . 

721192 

355107 

366085 

616912 

307237 

309675 

104280 

47870 

56410 

1920  . 

1 

733826 

361611 

372215 

625074 

308340 

316734 

108752 

53271 

55481 

180  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

RACIAL  COMPOSITION  OF  THE  POPULATION— WHITE. 

As  in  the  colony  of  Maryland,  so  in  early  Baltimore,  the  bulk  of  the  white 
population  was  of  English,  Welsh,  or  Scotch  descent.  In  the  earliest  records  of 
Baltimore  Town,  English  surnames  were  predominant  in  number,  with  a 
sprinkling  of  Scotch  and  Irish.  Many  of  those  bearing  Scotch  names  are  known 
to  have  immigrated  from  the  north  of  Ireland  and  have  often  been  erroneously 
classed  as  of  Irish  stock.  According  to  the  United  States  census  of  1790,  the 
208,604  white  inhabitants  of  Maryland,  classified  according  to  blood  or  nation¬ 
ality  strain,  as  determined  by  their  surnames,  were :  English  84  per  cent,  Scotch 
6.5  per  cent,  Irish  2.4  per  cent,  German  5.9  per  cent,  French  0.7  per  cent, 
Hebrew  0.3  per  cent,  Dutch  0.1  per  cent,  all  other  0.1  per  cent.  While  it  is 
probable  that  the  population  of  Baltimore  was  at  that  time  distributed  racially 
in  very  much  the  same  proportions,  it  is  likely  that  the  proportions  for  Germans 
and  for  Dutch  would  be  too  high  and  those  for  French  and  Jews  too  low,  for 
it  can  safely  be  assumed  that  most  of  the  people  with  German  and  Dutch  names 
in  Maryland  had  settled  in  the  counties  bordering  on  the  Pennsylvania  line, 
that  the  considerable  French  colony  would  have  attracted  many  of  their  asso¬ 
ciates  to  the  town,  and  that  nearly  all  of  the  Jews  would  have  settled  in  the 
largest  trading  town  of  the  State.  As  would  be  expected,  the  proportion  of 
people  of  British  extraction — English,  Welsh,  and  Scotch — was  largely  pre¬ 
dominant,  and  that  for  this  and  for  other  reasons  they  put  their  stamp  indelibly 
upon  the  life  and  characteristics  of  the  town  and  city. 

Owing  to  the  incompleteness  and  the  vagaries  of  the  reports  on  population 
issued  by  the  Bureau  of  the  Census,  it  is  impossible  to  determine  with  any  satis¬ 
factory  degree  of  accuracy  the  numbers  and  proportions  of  any  of  the  various 
stocks  of  the  white  race  in  Baltimore  for  the  different  census  years  since  1790. 
No  information  at  all  on  this  point  appears  before  1860.  However,  from 
figures  giving  the  number  of  foreign-born  from  various  countries  for  1860, 
1870,  and  1880,  and  for  the  number  of  foreign-born  of  various  countries  and 
of  native-born  of  such  parents  (the  immigrant  and  first  generation  in  Balti¬ 
more)  for  1890,  1900,  and  1910,  it  has  been  possible  to  make  estimates  of  the 
actual  numbers  of  representatives  of  certain  prominent  race  stocks  in  the 
population  as  of  1910.  Since  in  the  first  three  of  these  decennia  no  mention 
is  made  of  any  but  the  first  generation — the  immigrant,  and  in  the  last  three 
decennia  all  except  the  first  two  generations — the  immigrant  and  the  first 
generation  born  in  this  country — are  ignored  in  the  census  reports,  the 
resulting  estimates  may  be  regarded  as  only  rough  approximations  to  the  truth. 
The  results  are  further  complicated  by  the  fact  that,  for  the  most  part,  the 
immigrants  were  classified  geographically,  and  considerable  difficulty  has 
attended  the  extraction  of  Jews  from  Germany  and  Austria  from  ethnological 
Germans,  and  Poles  and  Bohemians  from  Austro-Germans,  who  in  turn  must 
be  classed  with  Germans.  As  British  have  been  classed  all  immigrants  from 
British  colonies  and  dominions  (except  French  Canadians),  as  well  as  those 
from  England,  Wales,  and  Scotland.  To  save  space,  the  essential  facts  selected 
from  an  elaborate  compilation  of  data  have  been  condensed  into  table  13, 
showing  the  numbers  and  percentages  contributed  by  each  important  race- 
stock  in  the  population  as  of  1910.  On  the  basis  of  these  two  estimates  and 
with  the  aid  of  pertinent  facts  supplied  by  local  chroniclers,  the  history  of  the 
growth  of  each  of  the  important  white  race-stocks  will  be  traced  in. 


POPULATION-  AND  STATISTICAL  DATA 


181 


The  British  element  has  received  additions  from  three  sources  by  migrants ; 
directly  from  England,  Wales,  Scotland,  and  Ireland,  especially  numerous  just 
before  and  after  the  War  of  the  Revolution  and  after  the  Napoleonic  Wars; 
from  British  colonies,  particularly  Canada  and  the  West  Indies;  and  from 
Maryland  and  other  colonies  and  States  as  Americans  of  British  descent.  Of 
these  groups,  the  last  is  the  most  important.  Members  of  this  group  were 
derived  especially  from  New  England,  New  York,  New  Jersey,  Delaware, 
Pennsylvania,  Virginia,  and  North  Carolina,  and,  to  a  less  degree,  in  later 
years,  from  western  States  and  States  farther  south.  These  people,  represent¬ 
ing  the  best  development  of  the  British  stock  in  this  country,  and  imbued  with 
the  spirit  of  adventure,  were  by  far  the  most  important  additions  gained  by 
migration.  The  influx  beginning  just  before  1776  was  particularly  strong  until 
about  1840,  and,  while  no  definite  figures  can  be  given,  it  seems  certain  that 
the  larger  proportion  of  these  people  were  contributed  by  New  England,  Mary- 


Table  13. — Population. 


Stock. 

Population. 

Percentage  of 
population  of  speci¬ 
fied  race  stock  to 
total  white 
population. 

British  . 

160000 

33.70 

German  . 

132000 

27.80 

Irish  . 

62500 

13.16 

Jewish  . 

50000 

10.53 

Polish  . 

22000 

4.63 

Bohemian  . 

10000 

2.11 

Italian  . 

10000 

2.11 

French  . 

8000 

1.68 

Unimportant  . 

20319 

4.28 

Total  white  population . 

474819 

100.00 

land,  and  Virginia.  After  the  Civil  War  there  was  a  particularly  heavy  migra¬ 
tion  of  people  from  Virginia  and  North  Carolina.  Fusing  readily  with  the 
local  population,  the  migrants  from  all  these  States  assumed  leading  roles  in 
thought,  education,  commerce,  finance,  and  the  professions.  It  is  probable  that 
from  1815  until  1860  there  was  a  considerable  migration  to  Baltimore  of 
Britons  from  the  mother  country  and  from  the  colonies.  The  census  figures 
from  1860  show  a  comparatively  small  but  steadily  increasing  immigration 
from  these  sources,  the  British-born  numbering  2,925  in  1860,  3,141  in  1870, 
3,448  in  1880,  3,637  in  1890,  4,182  in  1900,  and  4,087  in  1910.  This  stock, 
always  the  most  numerous  single  stock  forming  the  bulk  of  the  white  population 
before  1830,  probably  remained  in  the  majority  until  after  the  Civil  War. 
In  1910,  estimated  at  160,000,  it  formed  33  per  cent.  In  point  of  time,  due 
to  the  migrations  of  Acadians  in  1755  and  of  the  French  from  San  Domingo, 
people  of  French  extraction  composed  the  most  numerous  non-British  element. 
The  first  French  immigrants,  whose  exact  number  is  unknown,  were  sufficiently 
numerous  to  have  the  name  “  French  Town  ”  given  to  the  quarter  in  which 
they  were  settled,  and  must  have  formed,  for  a  time  at  least,  one-fourth  of  the 


182  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

population  of  Baltimore  Town.  They  were  notably  industrious  and  frugal, 
and  many  of  them  turned  to  ship-building.  The  second  migration,  comprising 
3,000,  and  including  an  unknown  number  of  negro  slaves,  left  San  Domingo  in 
consequence  of  the  revolution  and  reached  Baltimore  in  1793.  Many  of  them 
were  people  of  property,  education,  and  talent,  and  soon  took  a  leading  part  in 
the  business,  professional,  social,  and  religious  life  of  the  community.  Some 
of  the  most  distinguished  families  of  present-day  Baltimore  trace  their  ancestry 
to  these  immigrants.  In  1794  probably  20  per  cent  of  the  white  population  was 
of  French  blood.  Immigration  of  the  French  since  1793  has  been  small  and 
intermittent,  and  it  is  unlikely  that  there  were  more  than  8,000  people  of 
French  blood  in  Baltimore  in  1910. 

The  relation  of  the  Irish  to  Baltimore  is  of  peculiar  interest  and  impor¬ 
tance.  While  many,  both  Protestant  and  Catholic,  came  to  the  Maryland 
colony,  at  one  period  the  migration  of  the  latter  was  discouraged  by  a  discrim¬ 
inatory  tax.  Though  the  land  upon  which  Baltimore  Town  was  laid  out  was 
purchased  from  the  prominent  land-owning  Catholic  Carroll  family,  members 
of  which  were  early  identified  with  the  town,  it  does  not  appear  that  any  con¬ 
siderable  proportion  of  the  early  inhabitants  were  of  this  origin.  The  Catholic 
Irish,  who  really  represent  the  distinctively  Irish  race,  had  become  sufficiently 
numerous  by  the  last  of  the  eighteenth  century  to  play  an  important  part  in 
the  social,  commercial,  and  professional  life  of  the  town,  and  their  influence 
has  continually  grown.  To  what  extent  this  portion  of  the  population  was 
recruited  from  the  counties  of  Maryland,  from  other  colonies  or  States,  and 
by  direct  migration  from  Ireland  it  is  not  possible  to  state  with  exactness. 
Certain  it  is  that  after  the  peace  of  1815,  there  began  a  steady  stream  of  migra¬ 
tion  of  Catholic  Irish  from  Ireland  to  Baltimore,  which,  assuming  large  pro¬ 
portions  in  the  third  and  fourth  decades  of  the  nineteenth  century,  reached  its 
high  point  in  the  fifth  decade,  and,  continuing  at  a  slower  rate  until  1870,  had 
practically  died  out  in  1890.  According  to  the  census  reports,  there  were 
recorded  in  Baltimore  as  born  in  Ireland  15,511  persons  in  1860,  15,223  in 
1870,  14,238  in  1880,  13,659  in  1890,  9,690  in  1900,  and  6,806  in  1910.  Of 
Irish  birth  and  native-born  of  Irish  parentage,  there  were  38,051  in  1890, 
33,100  in  1900,  and  27,465  in  1910.  From  these  figures  it  would  appear  that  in 
1910  there  were  not  far  from  62,500  persons  of  Irish  Catholic  stock  in  Balti¬ 
more.  The  Protestant  Irish,  some  bearing  names  suggestive  of  English  origin 
but  most  of  them  evidently  of  Scotch  extraction,  have  been  included  among  the 
British.  They  have  taken  throughout  the  history  of  the  city  a  leading  part  and 
have  exercised  an  influence  out  of  proportion  to  their  number.  The  Stevenson 
brothers,  Henry,  the  leading  physician  of  his  day,  and  John,  the  founder  of 
Baltimore’s  commerce,  arrived  in  1745. 

The  Germans  came  to  Baltimore  early,  the  first  arriving  in  1752  from  Lan¬ 
caster,  Pennsylvania.  Dr.  Charles  Wiessenthal,  the  accomplished  physician 
and  Eevolutionary  patriot,  came  in  1755.  The  Germans  were  sufficiently  nu¬ 
merous  to  establish  a  Lutheran  Church  in  1758  and  in  1790  probably  exceeded 
800.  The  Germans,  mostly  from  the  Palatinate,  of  the  early  migration  took 
a  prominent  part  in  the  town  and  city  and  soon  merged  into  the  general  popu¬ 
lation  by  both  association  and  marriage.  The  later  accessions  came  in  greatest 
numbers  from  Prussia,  Saxony,  Wurttemburg,  Hanover,  and  Austria.  Bremen 


POPULATION  AND  STATISTICAL  DATA 


183 


enjoyed  a  large  commerce  with  Baltimore  by  1830,  and  during  the  third,  fourth, 
fifth,  sixth,  and  seventh  decades  of  the  nineteenth  century  there  was  a  strong  tide 
of  German  immigration  to  Baltimore.  The  peak  of  the  German  migration  was 
some  10  or  15  years  later  than  that  of  the  Irish.  The  number  of  German-born 
in  Baltimore  was  32,608  in  1860,  35,491  in  1870,  34,337  in  1880,  40,480  in 
1890,  34,564  in  1900,  and  25,104  in  1910.  The  German-born  and  native-born 
of  German  parentage  numbered  111,172  in  1890  and  declined  to  94,002  in 
1910.  All  these  figures,  however,  include  German  Jews.  If  100,000  be  taken 
as  the  approximate  number  of  German-born  and  native  children  of  true  Ger¬ 
man  stock  in  1890,  it  is  probable  that  in  1910  the  whole  number  of  representa¬ 
tives  of  this  stock  in  Baltimore  was  not  far  from  132,000. 

The  early  Jewish  settlers  in  Baltimore  probably  came  from  Holland  and 
England,  for  several  Jewish  families  of  distinction,  belonging  to  the  well- 
known  group  of  “Spanish”  Jews,  prominent  in  the  Netherlands  since  1492 
and  later  in  England,  settled  in  Baltimore  at  an  early  date.  With  this  excep¬ 
tion  the  Jewish  immigrants  to  Baltimore,  until  about  1884,  came  almost 
entirely  from  the  German  states  and  bear  typically  German  names.  This  immi¬ 
gration  probably  began  after  1830  and  practically  ceased  with  1870.  The  total 
Jewish  population  of  Baltimore  was  estimated  in  1880  as  about  10,000  by 
Dr.  Aaron  Eriedenwald,  a  distinguished  physician  and  publicist  of  that  race. 
With  additions  from  other  parts  of  this  country  and  by  natural  increase,  German 
Jews  probably  numbered  20,000  by  1910.  A  third  immigration  of  Jews,  result¬ 
ing  in  a  population  which  can  be  measured  with  a  considerable  degree  of  ac¬ 
curacy,  began  about  1884  from  Russian  Poland,  in  consequence  of  religious  and 
social  persecution.  The  foreign-born  Polish  Jews,  numbering  179  in  1880, 
increased  to  4,118  in  1890,  10,509  in  1900,  and  15,585  in  1910,  and  the  number 
of  native-born  of  such  parentage  (first  generation)  increased  from  1,435  in 
1890  to  11,557  in  1910.  Since  in  the  latter  year  the  combined  figure  for 
foreign-born  and  the  first  generation  of  descendants  was  27,142,  it  is  likely 
that  30,000  is  a  fair  estimate  of  the  total  number  of  Polish  Jews  at  that  date. 
Therefore,  the  whole  number  of  persons  of  Jewish  stock  in  Baltimore  in  1910 
may  be  reckoned  as  50,000. 

A  stream  of  emigrants  from  southern  and  southeastern  Europe  started  about 
1870.  Weak  at  first,  it  had  reached  considerable  proportions  by  1910.  In  order 
of  their  arrival  were  the  Bohemians,  who  in  1910  numbered  7,750  as  foreign- 
born  and  as  first-generation  native-born,  with  a  probable  total  of  10,000.  The 
Italian  migration,  starting  about  1870,  first  from  northern  but  later  almost 
entirely  from  southern  Italy  and  Sicily  and  gradually  increasing,  resulted  in 
the  presence  of  8,540  persons  of  foreign  birth  and  natives  of  the  first  generation, 
with  a  probable  total  of  10,000  of  this  stock  in  1910.  In  addition,  small  numbers 
of  people  of  diverse  stocks  have  come  from  Hungary,  Greece,  Bulgaria,  Serbia, 
Roumania,  and  Turkey. 

From  the  north  of  Europe  a  migration  of  Poles  started  about  1870,  reached 
considerable  size  by  1900,  and  by  1910  there  were  11,123  foreign-born  and 
10,476  native-born  of  the  first  generation,  with  a  probable  total  of  22,000.  In 
the  last  decade  of  the  nineteenth  and  the  first  decade  of  the  twentieth  century 
a  small  number  of  Lithuanians,  Letts,  Russians,  and  Finns  entered.  From  time 
to  time  there  have  come,  within  the  last  50  years,  a  small  number  of  persons 


184  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

from  Scandinavia,  Belgium,  Holland,  Switzerland,  Spain,  Portugal,  and  other 
countries  of  Europe  and  from  South  America.  The  total  of  these  races,  together 
with  immigrants  from  southern  Europe,  other  than  Italians  and  Bohemians, 
represent  the  group  of  numerically  unimportant  stocks  in  the  table,  estimated 
to  number  20,319  in  1910. 

The  percentages  of  actual  foreign-born  whites  to  the  total  whites  for  the 
decennia  from  1860  to  1910,  inclusive,  were  28.35,  24.70,  20.10,  18.60,  15.97, 
and  16.24,  respectively. 

From  the  foregoing  it  is  especially  to  be  noted  that  the  basic  race  stock  of 
Baltimore,  those  of  British  ancestry  descended  largely  from  English,  Welsh, 
and  Scotch  who  settled  in  the  colonies  or  in  the  States  of  the  United  States 
before  1820,  has  been  the  predominant  stock  numerically.  Until  1870  it  must 
have  comprised  considerably  over  50  per  cent  of  the  white  population. 

Up  until  1880  the  white  population  consisted  almost  exclusively  of  people  of 
British,  German,  Irish,  French,  and  Jewish  stocks,  with  the  first  three  very 
largely  in  excess,  who  had  been  in  association  through  many  years.  The  first- 
named  four  of  these,  though  divided  to  some  degree  by  relatively  minor  differ¬ 
ences,  had  long  since  become  fused  into  a  compact  citizenship  in  business  and 
social  life  and  even  in  intermarriage.  Since  1880,  new  and  important  racial  fac¬ 
tors  have  been  added  by  the  arrival  of  Poles,  Polish  Jews,  Bohemians,  Italians, 
Lithuanians,  and  others,  who  have  preserved  the  habits,  customs,  languages, 
and  racial  prejudices  peculiar  to  themselves  and  which  have  tended  to  cut  them 
off  from  each  other  and  from  the  rest  of  the  population.  To  a  very  large  degree 
they  live  in  colonies  and  work  and  worship  in  racial  groups. 

POPULATION  GROWTH— COLORED. 

Since  at  no  time  in  the  history  of  Baltimore  have  Indians  and  Mongolians 
been  numerous,  the  term  colored  has  meant  persons  of  African  negro  blood, 
either  pure  or  in  various  degrees  of  admixture  with  white  blood;  hence,  for 
convenience,  here  as  elsewhere  in  this  work,  the  word  negro  will  be  used  for 
colored.  There  exist  no  reliable  figures  for  the  negro  population  of  Baltimore 
before  the  census  of  1790.  The  rate  of  increase  in  the  decade  1790-1800  was 
high,  averaging  over  25  per  cent  per  annum,  continuing  at  a  relatively  high  level 
for  the  next  decade,  and  descending  irregularly  until  there  was  an  actual  loss 
in  population  in  the  sixth  decade.  There  was  a  decided  rise  between  1860  and 
1870,  then  the  rate  of  increase  fell  consistently  during  the  following  four 
decades.  Between  1910  and  1920  there  was  a  marked  increase.  Notwithstand¬ 
ing  these  wide  fluctuations  in  the  rate  of  increase,  between  1800  and  1840  the 
percentage  of  negroes  to  the  total  population  varied  within  narrow  limits,  the 
average  being  about  22  per  cent ;  after  dropping  during  the  sixth  decade  of  the 
nineteenth  century  to  13  per  cent,  it  gradually  rose,  so  that  from  1870  to  1920 
it  stood  close  to  15.5  per  cent.  Since  the  birth-rate  of  the  negro  in  Baltimore 
has  probably  never  approached  his  death-rate,  for  any  length  of  time  at  least, 
it  is  evident  that  his  growth  in  population  has  been  determined  almost,  if  not 
entirely,  by  immigration.  This  immigration  has  doubtless  been  governed  by 
demands  for  laborers  and  domestic  servants.  Whereas  the  number  and  percent¬ 
age  of  slave  negroes  increased  from  1790  to  1810,  after  the  latter  date  there 
was  a  gradual  decrease,  until  by  1860  they  numbered  less  than  in  1800.  In 


POPULATION  AND  STATISTICAL  DATA 


185 


1860  they  formed  only  1  per  cent  of  the  population  and  8  per  cent  of  the 
negroes.  It  is  evident  that  conditions  in  Baltimore  were  not  favorable  to  negro 
slavery.  On  the  other  hand,  the  city  has  had  strong  attractions  for  negro  immi¬ 
grants  who  have  come  particularly  from  the  States  of  Maryland,  Virginia, 
North  Carolina,  and  Georgia. 


NATALITY. 

LIVING  BIRTHS. 

No  record  of  living  births  was  kept  until  1875,  when  by  law  it  became  the 
duty  of  physicians  and  midwives  to  report  them.  Before  1912  the  health 
department  made  no  consistent  efforts  to  enforce  this  law,  and  it  was  not  until 
1915  that  Baltimore  was  included  among  the  birth-registration  cities.  Data 
for  the  live  births  recorded  annually  between  1875  and  1920  and  their  ratios 
to  the  total  population  and  to  whites  and  negroes  separately  are  given  in 
table  14.  It  is  evident  from  these  figures  that  birth  registration  was  very  defec¬ 
tive  until  1915.  In  the  whole  population  the  recorded  live  birth-rate  exceeded 
the  death-rate,  in  but  12  of  the  46  years  between  1875  and  1920,  and  in  only 
7  of  the  40  years  previous  to  1914.  In  the  37  years  between  1884  and  1920,  the 
official  birth-rate  surpassed  the  death-rate  in  whites  in  only  19  years  and  in 
negroes  in  only  2  years.  The  death-rate  exceeded  the  recorded  birth-rate  among 
whites  in  each  year  between  1898  and  1911,  inclusive.  Since  1912  the  birth¬ 
rate  has  been  well  above  the  death-rate  in  this  section  of  the  population.  Among 
negroes  this  discrepancy  between  birth  and  death  rates  obtained  in  every  year 
for  which  birth  records  exist,  except  in  1919  and  1920,  when  the  death-rates 
were  unusually  low  and  the  birth-rates  were  the  highest  recorded.  Since  1883 
in  only  one  year,  1918,  can  this  excess  of  deaths  over  births  so  frequently 
recorded  be  attributed  to  a  severe  epidemic.  For  the  six-year  period  1915-1920, 
during  which  it  may  be  held  that  live  births  were  reported  with  approximate 
completeness,  the  average  annual  birth  and  death  rates  per  1,000  living  popu¬ 
lation  were  for  whites,  24.43  and  16.50  and  for  negroes  24.62  and  28.43, 
respectively.  When  1918,  the  influenza  year,  with  its  exceptionally  heavy 
mortality,  is  left  out  of  consideration,  the  respective  rates  were  24.32  and 
15.05,  and  24.87  and  26.60.  Therefore,  in  recent  years,  on  an  average  for  each 
1,000  inhabitants  among  whites  the  excess  in  births  over  deaths  was  9,  while 
among  negroes  there  was  an  excess  of  1.7  in  deaths  over  births,  or,  in  other 
words  annually,  by  this  means,  the  whites  increased  by  almost  1  per  cent  and 
the  negroes  decreased  by  0.17  per  cent. 

The  vital  index,  i.  e.,  the  percentage  of  births  to  deaths,  proposed  by 
Pearl  (45)  as  a  delicate  test  in  the  study  of  population  growth,  may  be  used 
conveniently  here  to  measure  the  accuracy  of  reporting  of  living  births.  The 
vital  indices  for  the  total  population  for  whites  and  for  negroes  are  presented 
in  table  14.  It  will  be  observed  that  for  the  population  as  a  whole  the  vital 
index  exceeded  100  in  only  7  years  between  1875  and  1914,  and  in  only  4  years 
before  1912.  During  the  whole  period  from  1895  to  1912,  when  the  recorded 
birth-rate  was  always  below  20  per  1,000,  in  but  3  years  did  the  vital  index 
exceed  90.  Among  whites,  while  between  1884  and  1894  the  birth-rate  was 
always  between  20  and  22  per  1,000,  the  vital  index  was,  with  the  exception  of 


186  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


Table  14. — Number  of  recorded  births,  living  and  still,  percentage  of  still  to  total  births, 
and  rates,  per  100,000  living  inhabitants,  and  vital  indices  for  the  whole  population 
and  for  white  and  colored,  from  1875  to  1920,  inclusive. 


Year. 

Total. 

births. 

Still 

births. 

Per 
cent 
of  still 
births 
tototal 
births. 

Living  births. 

Total. 

White. 

Colored. 

No. 

Rate. 

Vital 

in¬ 

dex. 

No. 

Rate. 

Vital 

in¬ 

dex*. 

No. 

Rate. 

Vital 

in¬ 

dex. 

1875 

8735 

560 

6.4 

8175 

2683 

112.6 

1876 

7838 

588 

7.5 

7250 

2329 

96.7 

1877 

7146 

538 

7.5 

6608 

2078 

83.5 

1878 

6715 

655 

9.8 

6060 

1866 

90.0 

1879 

8227 

620 

7  5 

7607 

2294 

99.9 

1880 

9462 

636 

6.7 

8826 

2607 

109.7 

. 

1881 

9158 

651 

7  1 

8507 

2462 

96.5 

1882 

8436 

677 

8.0 

7759 

2200 

86.9 

. 

. 

. 

1883 

8605 

701 

8.1 

7904 

2197 

84.3 

1884 

•  • 

8881 

746 

8.4 

8025 

2186 

96.8 

6889 

2217 

107.7 

1136 

2015 

59.9 

1885 

•  • 

8390 

650 

7.7 

7740 

2067 

94.9 

6632 

2093 

104.9 

1108 

1927 

60.6 

1886 

*  # 

8415 

718 

8.5 

7694 

2015 

92.3 

6481 

2005 

100.1 

1213 

2069 

65.1 

1887 

•  • 

9726 

699 

7.2 

9027 

2319 

107.8 

7765 

2356 

121.7 

1262 

2112 

63.4 

1888 

•  • 

9419 

694 

7.4 

8725 

2079 

97.6 

7500 

2108 

108.8 

1225 

1923 

60.0 

1889 

•  • 

10149 

784 

7.7 

9365 

2193 

107.6 

8102 

2237 

118.8 

1263 

1947 

67.0 

1890 

10198 

800 

7.8 

9398 

2163 

92.2 

8226 

2232 

102.5 

1172 

1776 

54.0 

1891 

•  • 

10150 

811 

8.0 

9339 

2113 

92.7 

8238 

2198 

105.1 

1101 

1640 

49.3 

1892 

•  • 

10247 

813 

7.9 

9434 

2099 

89.2 

8087 

2122 

96.7 

1347 

1972 

60.6 

1893 

•  • 

9905 

770 

7.8 

9135 

2000 

95.6 

7914 

2043 

107.4 

1221 

1757 

55.9 

1894 

•  • 

10104 

721 

7.1 

9383 

2022 

98.9 

8030 

2041 

110.9 

1353 

1916 

60.3 

1895 

•  • 

8725 

666 

7.6 

8059 

1709 

78.2 

7667 

1919 

97.2 

1392 

1938 

57.6 

1896 

•  • 

9472 

678 

7.2 

8794 

1837 

88.7 

7495 

1848 

98.5 

1299 

1779 

56.3 

1897 

•  • 

9506 

706 

7.4 

8800 

1811 

94.3 

7382 

1793 

103.1 

1418 

1911 

65.5 

1898 

•  • 

9541 

748 

7.8 

8793 

1784 

84.7 

7227 

1731 

91.4 

1566 

2078 

63.2 

1899 

•  • 

8739 

701 

8.0 

8038 

1607 

79.2 

6796 

1604 

87.5 

1242 

1622 

52.0 

1900 

•  • 

9335 

682 

7.3 

8653 

1707 

80.9 

7242 

1687 

89.5 

1411 

1815 

54.1 

1901 

•  • 

9467 

672 

7.1 

8795 

1712> 

83.9 

7125 

1638 

90.7 

1670 

2115 

63.7 

1902 

•  • 

9609 

659 

6.9 

8950 

1719 

87.3 

7193 

1633 

93.0 

1757 

2192 

69.7 

1903 

•  • 

9361 

741 

7.9 

8620 

1634 

85.0 

7001 

1569 

91.4 

1619 

1991 

65.2 

1904 

•  • 

9309 

710 

7.6 

8599 

1610 

79.5 

6863 

1520 

84.7 

1736 

2104 

63.9 

1905 

•  • 

9765 

814 

8.3 

8951 

1655 

83.7 

7077 

1549 

89.1 

1874 

2238 

68.0 

1906 

•  • 

9928 

826 

8.3 

9102 

1663 

84.6 

7300 

1579 

90.9 

1802 

2122 

66.3 

1907 

•  • 

9555 

794 

8.3 

7861 

1583 

78.3 

7128 

1525 

85.1 

1633 

1896 

58.1 

1908 

•  • 

9989 

811 

8.1 

9178 

1639 

88.0 

7564 

1600 

96.1 

1614 

1849 

63.0 

1909 

•  • 

9613 

817 

8.5 

8796 

1554 

84.8 

7313 

1531 

93.9 

1483 

1676 

57.4 

1910 

•  • 

10680 

822 

7.7 

9858 

1723 

91.7 

7941 

1645 

97.5 

1917 

2138 

73.5 

1911 

•  • 

9995 

712 

7.1 

9283 

1605 

89.2 

7592 

1558 

97.8 

1691 

1861 

63.9 

1912 

•  • 

12087 

689 

5.7 

11398, 

1951 

109.2 

9387 

1907 

119.1 

2011 

2185 

78.5 

1913 

•  • 

13451 

909 

6.8 

12542 

2126 

123.3 

10309 

2075 

131.3 

2233 

2396 

96.3 

1914 

•  • 

13663 

1026 

7.5 

12637 

2121 

119.8 

10665 

2127 

134.8 

1972 

2089 

74.8 

1915 

•  • 

14765 

1131 

7.7 

13634 

2267 

136.3 

11460 

2265 

152.3 

2174 

2275 

87.8 

1916 

#  # 

16320 

1235 

7.6 

15085 

2485 

140.7 

12662 

2482 

158.6 

2423 

2505 

88.6 

1917 

•  • 

16217 

1267 

7.8 

14950 

2441 

131.6 

12582 

2445 

150.5 

2368 

2420 

78.9 

1918 

•  • 

16492 

1200 

7.3 

15292 

2476 

95.4 

12975 

2502 

105.4 

2317 

2340 

62.3 

1919 

•  • 

18958 

1327 

7.0 

17631 

2445 

154.2 

14908 

2417 

167.7 

2723 

2611 

107.0 

1920 

•  • 

20185 

1398 

6.9 

18787 

2560 

165.4 

15934 

2549 

181.5 

2853 

2623 

110.7 

POPULATION  AND  STATISTICAL  DATA 


187 


a  single  year,  invariably  above  100,  from  1895  to  1912,  with  birth-rates  con¬ 
sistently  below  20,  the  vital  index  was  under  par  in  every  year  except  2.  With 
the  increase  in  the  recorded  birth-rate  after  1915,  the  vital  index  for  whites 
rose  to  levels  characteristic  for  a  population  growing  rapidly  by  excess  of 
births  over  deaths.  Between  1884  and  1911  the  vital  index  for  negroes  was 
commonly  below  60  and  never  exceeded  70,  but  in  one  year.  It  is  true  that  for 
the  negro,  with  the  high  death-rate  that  existed  during  all  these  years,  a  birth¬ 
rate  of  well  over  30  per  1,000  population  would  have  been  necessary  for  a  vital 
index  of  100.  It  was  not  until  the  considerable  fall  in  the  death-rate,  togetner 
with  the  rise  in  the  recorded  birth-rate,  that  the  vital  index  for  this  race  rose 
above  100.  The  conclusion  is  inevitable  that  until  1916  the  reporting  of  live 
births  was  far  from  complete  in  both  races,  and  that  the  losses  in  population 
presaged  by  the  official  figures  were  apparent  and  not  real. 

It  is  not  possible  from  the  data  at  hand  to  estimate  with  any  accuracy  the 
probable  birth-rates  for  the  white  and  negro  populations  previous  to  1916. 
It  is  probable,  however,  that  since  1812,  the  white  live  birth-rate  has  rarely  if 
ever  fallen  below  20  and  has  often  been  higher  than  30  per  1,000  inhabi¬ 
tants.  It  is  reasonably  certain  that  during  this  period,  except  in  connection 
with  unusually  severe  epidemics,  there  has  been  for  this  race  a  comfortable 
annual  surplus  of  live  births  over  deaths,  which  would  have  insured  a  steady 
but  moderate  increase  of  population  independent  of  immigration.  It  is  likely 
that  on  the  whole  the  live  birth-rate  has  been  higher  in  the  negro  than  in  the 
white  race.  With  his  much  higher  death-rates,  however,  only  in  exceptional 
years  could  the  births  have  exceeded  the  deaths  in  this  race.  It  follows,  then, 
that  by  and  large  the  white  population  has  undergone  a  healthy  natural  increase 
and  that  the  negro  population  has  not  been  self-sustaining  in  the  same  sense, 
and  its  actual  increase  has  been  due  entirely  to  immigration. 

Data  regarding  the  relative  frequency  of  legitimate  and  illegitimate  births 
and  their  distribution  by  color  and  sex,  available  since  1900,  are  presented  in 
table  15.  Of  the  whole  number  of  living  births  reported  within  these  periods, 
6.6  per  cent  were  illegitimate.  The  proportions  of  illegitimacy  among  whites 
and  negroes  were  3.1  per  cent  and  23.8  per  cent,  respectively.  The  proportion 
of  males  to  females  was,  for  total  births,  among  whites  as  1.06  to  1  and  among 
negroes,  as  1.05  to  1,  and  for  illegitimate  births  1.04  to  1  among  whites  and 
1.004  to  1  among  negroes. 

STILL-BIRTHS. 

Still-births  have  been  recorded  in  the  statistical  tables  in  every  year  since 
1812,  but  not  until  1900  were  they  classified  according  to  sex  and  color.  The 
recorded  data  concerning  still-births  are  presented  in  tables  132,  14,  15,  and 
126.  Nowhere  in  the  records  is  still-birth  defined.  It  is  unlikely  that  whatever 
definition  custom  had  established  was  seriously  modified,  except  under  very 
unusual  circumstances.  It  is  probable,  therefore,  that  on  the  whole  until 
very  recent  years,  a  still-birth  represented  a  dead-born  fetus  of  at  least  5  full 
months  of  utero-gestation.  During  the  last  10  years,  due  partly  to  the  pressure 
of  the  administrative  authorities  and  partly  to  the  request  of  the  department 
of  anatomy  of  the  Johns  Hopkins  Medical  School,  physicians  have  become 
accustomed  to  reporting  some  fetuses  of  much  earlier  stages  of  development. 

13 


Table  15. — Number  of  total,  illegitimate  and  still-births  by  color  and  sex,  from  1900  to  1920,  inclusive. 


188  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


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POPULATION  AND  STATISTICAL  DATA 


189 


As,  with  this  exception,  both  before  and  after  1875,  when  death  and  birth 
certificates  were  first  required,  the  only  reason  for  reporting  still-births  would 
have  been  to  escape  charges  of  infanticide  and  to  secure  burial,  it  is  reasonable 
to  suppose  that  the  registration  of  births  of  dead-born  fetuses  was  limited  to 
those  near  or  well  above  viable  size  and  age,  i.  e.,  of  at  least  the  stage  of  develop¬ 
ment  compatible  with  extra-uterine  survival  of  live:born  fetuses. 

Since  for  every  locality  there  is  generally  a  very  definite  relation  between  the 
number  of  live  and  still  births,  the  proportion  of  still-births  may  be  expected 
to  fluctuate  with  the  birth-rate,  i.  e.,  the  proportion  of  live-born  chidren.  This 
has  probably  varied  within  wide  limits  in  Baltimore  as  elsewhere.  Another 
factor  of  recognized  importance,  but  one  which  can  not  be  measured  here  with 
any  degree  of  exactness,  is  the  variation  in  the  character  of  obstetrical  care  and 
of  the  inherent  maternal  qualities  of  the  women.  Finally,  there  must  be  taken 
into  account  the  variations  in  the  prevalence  of  certain  general  and  local  dis¬ 
eases  which  are  known  to  be  fatal  to  fetuses,  such  as  small-pox,  influenza, 
pneumonia,  yellow,  typhus,  and  typhoid  fevers,  syphilis,  and  gonorrhoea. 

In  the  absence  of  specific  information  regarding  the  true  live  birth-rate 
previous  to  1916,  the  frequency  of  still-births  can  only  be  estimated  by  round¬ 
about  methods.  From  table  132,  it  will  be  observed  that  the  rates  for  recorded 
still-births  as  calculated  on  the  basis  of  the  whole  population  show  very  wide 
fluctuations  over  much  of  the  109-year  period  for  which  they  may  be  followed. 
The  highest  and  lowest  rates  recorded  were  276  in  1812,  and  102  in  1862.  The 
rates  declined,  but  in  a  rather  irregular  fashion,  from  1812  to  1828,  when  the 
low  level  of  113  was  reached.  This  was  a  period  of  heavy  mortality  from 
malarial,  yellow,  and  typhus  fevers  and  pneumonia,  all  of  which  had  fallen 
considerably  by  1828.  During  this  period,  in  connection  with  the  financial 
depression  following  the  war,  the  total  birth-rate  probably  declined  sharply. 
The  gradual,  but  somewhat  irregular  rise  in  the  rates  from  1829  to  1847,  when 
the  rate  stood  between  240  and  258  for  this  and  the  next  3  years,  and  the 
succeeding  decline  during  the  following  12  years  to  102  in  1862,  suggest  a 
corresponding  rise  and  fall  in  the  birth-rate.  The  low  still-birth  rate  during 
and  immediately  following  the  Civil  War  suggests  that  the  total  birth-rate 
declined  materially  in  this  period.  By  1870  the  still-birth  rate  had  risen  to  194. 
The  sharp  decline  in  1873  and  1874  may  have  been  associated  with  a  fall  in 
total  birth-rate  under  the  influence  of  the  small-pox  epidemic  of  this  time. 
From  1875  to  1892  the  rate  for  still-births  was  comparatively  high  and  varied 
within  rather  narrow  limits.  During  the  period  from  1895  to  1915  of  very  low 
recorded  live-birth  rates  already  alluded  to,  the  still-birth  rates  were  corre¬ 
spondingly  low.  While  this  correspondence  was  perhaps  due  to  low  actual  birth¬ 
rates,  it  is  more  than  likely  that  the  meager  rates  were  in  both  cases  the  direct 
result  of  poor  registration.  It  is  to  be  noted  that  the  rates  for  still-births  rose 
after  1912  and  by  1915  had  reached  the  level  of  1875-1892,  which  was  main¬ 
tained  from  1916  to  1920.  From  table  14  it  appears  that  from  1875  to  1920 
the  ratio  of  still  to  the  total  recorded  births,  both  live  and  still,  varied  but 
slightly  from  year  to  year.  When  the  still-birth  rate  (table  132)  is  compared 
with  the  death-rate  for  women  in  child-birth  (table  124),  both  calculated  on 
the  basis  per  100,000  population,  it  is  found  that,  with  a  few  notable  exceptions, 
the  two  rates  rose  and  fell  together.  These  correspondences  suggest  very 


190  PUBLIC  HEALTH  ADMINISTKATIOX,  ETC.,  IN  BALTIMOBE 

strongly  that  during  the  period  in  which  live  births  have  been  reported,  on  an 
average,  whether  reporting  was  complete  or  incomplete,  the  registration  of  still 
and  live  births  has  been  maintained  at  about  the  same  ratio. 

During  the  whole  period  since  1875  the  proportion  of  still  to  total  reported 
births  has  been  unusually  high,  well  over  7  per  cent.  The  more  exact  registra¬ 
tion  of  the  last  few  years  gave  results  not  far  different,  the  average  for  the 
6-year  period  1915-1920  being  7.4  per  cent.  For  1919  and  1920  the  ratios  were 
5.9  per  cent  for  whites  and  12.8  per  cent  for  negroes.  As  it  is  improbable  that 
these  proportions  have  varied  widely,  it  is  safe  to  assume  that  these  remarkably 
high  ratios  of  still  to  total  births  have  obtained  constantly  in  Baltimore.  From 
the  data  compiled  in  table  15,  it  is  evident  that  a  much  larger  proportion  of 
still-born  fetuses  were  of  the  male  than  of  the  female  sex,  the  ratios  being  1.55 
to  1  for  whites  and  1.35  to  1  for  negroes. 


Chapter  IX. — Statistical  Material. 

Character;  Sources;  Uses;  Methods. 

In  the  annual  reports  of  the  health  department,  which  are  preserved  since 
1827  in  continuous  series,  there  are  given  the  amounts  of  money  appropriated 
for  expenses.  In  the  early  reports,  the  appropriations  and  expenditures  are 
given  under  separate  headings  for  office  administration,  salaries  of  commis¬ 
sioners  and  clerks,  for  the  quarantine  office  and  station,  for  the  control  of 
nuisances,  and  for  the  removal  of  garbage  and  the  cleaning  of  streets.  As  the 
department  expanded  after  1870,  it  is  possible  to  trace  and  to  separate  with 
some  degree  of  accuracy  the  sums  spent  on  certain  activities  in  connection  with 
attempts  to  control  some  of  the  diseases  amenable  either  to  general  or 
specific  measures,  as  for  instance,  small-pox,  tuberculosis,  or  the  communicable 
diseases  as  a  group,  by  fumigations,  the  health  warden  system,  etc.  It  is 
possible  to  find  the  sums  appropriated  for  the  divisions  of  chemistry,  bacteri- 
ology,  plumbing,  or  nursing,  for  example,  for  terms  of  years.  However,  when 
it  comes  to  the  evaluation  of  any  of  these  activities  by  themselves,  or  in  groups, 
it  is  practically  impossible  to  obtain  information  sufficiently  definite  to  mean 
anything  when  expressed  in  terms  of  disease  control. 

Taking  garbage  removal  as  an  illustration  of  a  public-health  service :  In  the 
first  place,  it  was  sometimes  done  by  contract,  sometimes  by  laborers  appointed 
by  the  health  department,  and  sometimes,  as  after  1882,  by  a  separate  depart¬ 
ment  of  the  city  government;  in  the  second  place,  this  function  has  been 
inseparably  bound  up  with  the  cleaning  of  streets,  and  from  time  to  time 
with  the  cleaning  of  sewers.  The  problems  of  garbage  removal,  of  street 
cleaning,  and  of  sewer  cleaning  have  varied  widely  at  different  periods  in  the 
history  of  the  city;  the  purchasing  value  of  money  has  also  been  subject  to 
considerable  changes. 

If  it  is  sought  to  estimate  the  influence  of  money  spent  upon  the  control  of 
the  communicable  diseases  as  a  group,  the  sums  of  the  appropriations  for  the 
laboratories,  the  health  wardens,  fumigation  and  disinfection,  the  small  isola¬ 
tion  hospital  and  the  quarantine  station,  the  nursing  and  plumbing  divisions, 
and  school  inspection  would  not  include  the  whole  amount  so  spent,  and  com¬ 
parisons  of  the  per  capita  cost  with  the  death-rates  from  these  diseases  would 
not  bear  any  accurate  relation  to  each  other. 

It  is  not  possible  to  determine  the  sums  expended  on  water  supplies  and 
service,  nor  to  apportion  the  huge  sums  invested  during  late  years  in  the  con¬ 
struction  and  maintenance  of  a  double  system  of  sewers;  nor  can  any  correct 
estimate  be  made  of  the  cost  borne  by  householders  in  connecting  properties 
with  these  sewers.  No  one  who  is  acquainted  with  what  is  known  of  the  history 
of  these  matters  would  attribute  any  value  to  such  comparisons.  All  that  can  be 
done  intelligently  in  this  direction  is  to  attempt  in  the  proper  places  in  relation 
to  the  discussion  of  the  courses  of  certain  groups  of  diseases  to  picture  the  con¬ 
ditions  obtaining  and  the  specific  actions  of  the  health  department  aimed  at 

191 


192  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


their  control  at  different  times.  What  is  wanted  in  this  connection  is  knowl¬ 
edge  of  conditions  and  actions  and  not  inaccurate  guesses  at  the  amount 
of  money  appropriated  at  particular  times  for  indefinite  services.  It  is  certain 
that  sums  appropriated  have  ever  fallen  short  of  the  desires  and  recommenda¬ 
tions  of  the  health  authorities,  and  that,  in  many  instances,  the  city  authorities 
exercised  good  judgment  in  this  respect. 

STATISTICAL  NOSOLOGY. 

The  early  statistical  nosology  was  primitive  and,  as  in  the  old  London  Bills 
of  Mortality,  the  deaths  were  classified  in  alphabetical  order  by  names  of 
diseases  or  of  prominent  symptoms  without  regard  to  anatomical,  causal,  or 
other  relationships,  except  in  the  case  of  fevers,  under  which  heading  were 
grouped  together  in  alphabetical  sequence  some  of  the  prominent  affections  of 
which  fever  is  a  conspicuous  symptom.  This  method  is  well  illustrated  in  the 
following  copy  of  the  list  of  interments  for  1819 : 


List  of  interments  for  1819. 


Abscess  .  1  Hives  . 

Apoplexy  .  21  Jaundice  . 

Asthma  .  5  Intemperance  . 

Burn  .  2  Insanity  . . 

Cancer  .  4  Inflammation  of  stomach . 

Casualty  .  17  Inflammation  of  lungs . 

Childbed  .  18  Inflammation  of  bowels . 

Cholera  morbus  .  125  Inflammation  of  brain . 

Cholic  .  4  Lockjaw  . 

Consumption  .  272  Measles  . 

Convulsions  .  89  Mortification  . 

Cramp  in  stomach .  3  Murdered  . 

Croup  .  57  Old  age  . 

Decay  .  88  Palsy  . 

Dropsay  .  41  Pleurisy  . 

Do.  in  the  head .  27  Rheumatism  . 

Drowned  .  31  Scrofula  . 

Dysentery  .  21  Small-pox  . 

Epilepsy  .  4  Sore  throat  . 

Fever  .  4  Spasm  . 

bilious  .  73  Still-born  . 

inflammatory  .  2  Sudden  death  . 

intermittent  .  4  Do.  by  drinking  cold  water 

malignant  .  350  Suicide  . 

nervous  .  2  Syphilis  . 

remittent  .  2  Teething  . 

typhus  .  84  Whooping-cough  . 

Flux  .  5  Worms  . 

Fistula  .  1  Unknown  . 

Gravel  .  3 

Gout  .  1  Total  . 

Haemorrhage  .  3 


Under  1  year . 

Between  1  and  2  years 
Between  2  and  5  years 
Between  5  and  10  years 
Between  10  and  20  years 
Between  20  and  30  years 
Between  30  and  40  years 
Between  40  and  50  years 


51G  Between  50  and  60  years 

252  Between  60  and  70  years 

129  Between  70  and  80  years 

147  Between  80  and  90  years 

291  Between  90  and  100  years 

357  Over  100  years . 

191  Still-born  . 

117 


There  were  1,716  white  deaths  and  571  colored  deaths. 


3 

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116 

26 

7 

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7 
41 

5 

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11 

3 

105 

16 

8 
3 
3 

27 

78 
59 
91 


2,287 


71 

39 

35 

27 

9 

1 

105 


POPULATION  AND  STATISTICAL  DATA 


193 


The  first  indication  of  an  anatomical  grouping  appeared  when,  under  inflam¬ 
mations,  those  affecting  different  organs  were  grouped  together  in  alphabetical 
order.  This  innovation  was  quite  illogical  in  certain  respects,  for  only  a  part  of 
the  so-called  inflammatory  diseases  were  thus  treated  and  no  distinction  was 
drawn  between  acute  and  chronic  affections.  The  terms  inflammation  of  the 
lungs,  peripneumonia,  and  pleurisy  all  may  appear  in  the  same  table.  Acute 
rheumatism,  a  febrile  and  inflammatory  affection,  was  not  included  under 
either  fevers  or  inflammation  of  joints,  but  appeared  as  a  separate  rubic. 
Abscess  also  appeared  under  a  separate  heading.  Scarlet  fever  was  classified 
with  fevers,  and  measles,  mumps,  small-pox,  and  chicken-pox  were  not.  Organic 
diseases  of  the  heart  and  angina  pectoris  were  separated  by  the  distance  of 
their  initial  letters.  Cirrhosis  of  the  liver  could  not  be  distinguished  from 
abscess  of  this  organ,  and  abscess  of  the  liver  might  be  hidden  under  abscess 
or  under  inflammation  of  the  liver.  This  crude  nosology  admitted  of  no  study 
of  the  relative  frequency  of  deaths  due  to  diseases  of  various  organs.  The 
number  of  items  in  the  list  was  gradually  expanded  so  that  by  1850  they  num¬ 
bered  95 ;  in  1863  they  had  contracted  to  83 ;  there  were  106  in  1873,  108  in 
1880,  268  in  1890,  and  323  in  1898.  This  expansion  was  brought  about  partly 
by  distribution  of  certain  affections  among  the  various  organs,  as  congestion, 
hemorrhage,  abscess,  tuberculosis,  cancer,  tumor,  and  stone,  and  by  the  separa¬ 
tion  of  acute  and  chronic  diseases  of  certain  organs,  as  the  brain,  liver,  and 
kidneys.  Nephritis  first  appeared  in  1850  and  diabetes  in  1851.  This  crude 
form  of  classifying  deaths  has  imposed  great  labor  and  care  in  the  compilation 
of  the  figures  for  the  different  causes  of  death  that  it  is  possible  to  separate 
out  and  trace  through  the  whole  period.  In  the  early  reports  a  considerable 
number  of  deaths  were  unclassified,  being  grouped  under  “  causes  unknown.” 
As  late  as  1837,  529  deaths  were  so  grouped,  of  which  519  were  “  infantile.” 
Fortunately,  the  great  mass  of  the  deaths  assigned  to  “  causes  unknown  ”  were 
in  infants,  probably  recently  born  for  the  most  part,  so  that  the  figures  for  such 
diseases  as  pulmonary  tuberculosis,  the  exanthematous  diseases,  and  other 
affections  which  caused  the  death  of  older  children  and  adults  were  not  seri¬ 
ously  affected  by  this  circumstance.  With  the  introduction  of  death  certificates 
in  1875,  the  number  of  deaths  attributed  to  “  causes  unknown  ”  greatly 
decreased. 

In  the  classification  of  deaths  in  the  annual  list  of  deaths  by  causes,  the  offi¬ 
cials  of  the  Baltimore  health  department  were  completely  oblivious  to  the  prog¬ 
ress  made  elsewhere,  especially  in  England,  Switzerland,  France,  and  Sweden, 
under  the  influence  of  Farr,  D’Espine,  Bertillon,  and  others,  and  in  this  country 
by  the  committee  of  the  American  Medical  Association  in  1847.  Joynes  in 
1850  (46)  and  Charles  Frick  in  1855  (47),  in  analyzing  the  deaths  in  Balti¬ 
more  classified  them  according  to  the  latter  system,  which  was  evidently  largely 
copied  from  Farr’s,  but  the  force  of  inertia  in  the  health  department  was  not 
overcome  until  1900.  In  this  year  there  was  a.  complete  change  in  the  statisti¬ 
cal  nosology,  modified  from  the  Bertillon  classification,  under  15  headings: 
(1)  Epidemic  diseases;  (2)  general  diseases,  containing  a  curious  mixture; 
(3)  diseases  of  the  nervous  system;  (4)  diseases  of  the  circulatory  system; 
(5)  diseases  of  the  respiratory  system;  (6)  diseases  of  the  digestive  system; 
(7)  diseases  of  the  genito-urinary  system;  (8)  diseases  of  the  puerperal  state; 
(9)  diseases  of  the  skin  and  cellular  tissue;  (10)  diseases  of  the  locomotor 


194  PUBLIC  PIEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

system;  (11)  malformations;  (12)  diseases  of  infancy;  (13)  affections  of 
old  age;  (14)  deaths  due  to  violence;  (15)  causes  ill  defined.  The  rubrics  were 
not  numbered.  In  1902,  the  first  two  headings  were  combined  under  general 
diseases.  The  international  classification  of  the  causes  of  death  was  adopted  in 
1903,  with  the  causes  of  death  under  189  headings. 

REPORTS  OF  DEATHS. 

Records  of  deaths  have  been  collected  and  compiled  by  the  health  department 
since  179?.  The  annual  reports,  first  issued  in  1817,  have  contained  a  list  of 
deaths  by  causes,  but  with  the  exception  of  the  report  for  1819  preserved  in 
the  library  of  the  Medical  and  Chirurgical  Faculty  of  Maryland,  none  are 
available  before  1827.  Since  the  latter  date  the  files  are  complete,  those  between 
1827  and  1849  having  been  collected  and  bound  in  a  single  volume  in  the 
City  Library,  and  those  for  1850  and  succeeding  years  are  in  the  health  depart¬ 
ment.  Owing  to  the  fortunate  circumstance  that  weekly  and  annual  tables  of 
interment  from  1812  to  1832  are  to  be  found  in  the  files  of  the  Baltimore 
American  and  Commercial  Advertiser,  it  has  been  possible  to  follow  the  record 
back  to  1812.  Since  these  data  correspond  in  number  and  classification  with 
those  of  the  annual  reports  for  1819  and  1827-1832,  and  with  those  published 
from  time  to  time  in  the  Weekly  Register  by  Niles  and  Russ,  they  may  be 
regarded  as  official.  The  records  of  the  deaths,  therefore,  are  available  in 
unbroken  series  since  1812. 

Before  death  certificates  were  required  by  law  in  1875,  the  tables  of  inter¬ 
ments  were  compiled  from  weekly  reports  made  to  the  health  department  by 
the  sextons  of  the  cemeteries.  The  records  of  the  sextons  were  apparently  com¬ 
plete  and  faithful  in  regard  to  color,  sex,  and  age,  for  even  the  early  tables  give 
data  for  these.  Concerning  the  causes  of  death  they  are  less  trustworthy,  and 
the  number  classed  as  due  to  “  causes  unknown,”  in  both  infants  and  adults, 
forms  a  large  proportion  in  the  tables  for  the  early  years. 

There  is  no  record  of  the  employment  of  official  searchers  to  ascertain  the 
causes  of  death.  The  cemeteries  were  either  within  the  city  limits  or  conveni¬ 
ently  near.  Only  when  a  body  was  removed  to  a  distance  for  burial  is  it  probable 
that  the  record  of  the  death  was  missed.  Wynne,  writing  in  1849,  expressed  the 
opinion  that  most  of  the  deaths  were  returned  and  that  the  tables  were  sub¬ 
stantially  correct  in  regard  to  numbers.  As  previously  stated,  the  deaths  of  those 
dying  at  the  almshouse  and  at  the  almshouse  hospital,  the  quarantine  (in¬ 
cluding  the  so-called  marine)  hospital,  and  later  the  Sydenham  Hospital, 
were  not  included  among  the  city  deaths.  These  comprised  a  not  inconsider¬ 
able  number.  Since  1900,  deaths  at  the  almshouse  or  Bayview  Hospital  and 
Sydenham  Hospital  have  been  so  included.  The  deaths  among  the  insane  and 
the  tuberculous  residents  of  the  city  dying  at  State  and  private  hospitals  and 
sanatoria  without  the  city  are  not  transferred,  but  are  charged  against  the 
counties  in  which  these  institutions  are  located.  At  the  sanatoria  for  the  tuber¬ 
culous,  the  deaths  of  city  residents  have  averaged  about  125  annually  since 
1913.  Until  1856,  the  still-born  were  included  with  the  deaths,  but  as  a  separate 
item. 

From  the  beginning,  the  reports  contained  tables  giving  the  number  of 
deaths  from  all  causes  by  age  of  decedents,  as  under  1  year,  between  1  to  2 


POPULATION  AND  STATISTICAL  DATA 


195 


years,  2  to  5  years,  5  to  10  years,  and  thereafter  decennially.  The  deaths 
are  classified  by  race  for  white  and  colored  (colored  divided  into  free  and  slave), 
and  by  sex  for  the  total.  It  is  not  possible  to  determine  with  accuracy  the 
number  of  deaths  by  color  and  sex  until  1857,  because,  before  that  date, 
m  the  special  tables  of  deaths  for  color  and  sex  as  set  up,  still-births  were 
included  and  males  and  females  were  not  separated  as  to  color.  Therefore, 
until  1857,  the  rates  for  white  and  colored  as  calculated  in  the  tables  presented 
are  of  necessity  based  upon  figures  for  deaths  inclusive  of  still-births.  In  the 
early  years  the  deaths  of  colored  free  and  slaves  were  not  classified  by  sex.  Since 
1857,  deaths  from  all  causes  are  classified  by  sex  and  color  in  correlated  form. 
It  has  not  been  possible  to  obtain  any  of  the  original  reports  of  the  sextons  to 
the  health  department. 

The  form  of  death  certificate  first  in  use  after  the  law  of  1875  called  for  the 
name,  address,  age,  sex,  race  (white  or  colored),  birthplace,  duration  of  illness, 
cause  of  death,  and  signature  of  the  attending  physician.  Since  deaths  recorded 
in  1874  and  1875  show  no  considerable  variation  in  number,  either  for  all 
causes  or  for  the  more  important  causes  of  death,  it  is  likely  that  under  the 
previous  system  not  many  deaths  within  the  city  were  unrecorded.  With  the 
passage  of  time,  the  information  required  on  the  death  certificates  was  made 
more  comprehensive,  and  in  1899  the  standard  death  certificate  was  adopted. 

STATISTICAL  STUDIES  RELATING  TO  CAUSES  OF  DEATH. 

It  is  notable  that  though  in  the  early  reports  attention  is  directed  from  time 
to  time  to  an  unusually  large  number  of  deaths  ascribed  to  some  particular 
diseases,  such  as  cholera,  yellow  fever,  small-pox,  typhus  fever,  measles,  scarlet 
fever,  or  to  the  high  mortality  of  infants,  it  was  not  until  1875  that  any  real 
use  was  made  of  statistical  methods  in  the  Baltimore  health  department  to 
determine  the  relative  importance  of  different  diseases  as  causes  of  death,  and 
only  in  occasional  years  were  even  the  crude  death-rates  calculated.  This 
omission  is  the  more  curious  because  Wynne  in  1849,  Levin  S.  Joynes  in  1850, 
and  Charles  Frick  in  1855  published  interesting  studies  of  mortality  in  Balti¬ 
more,  in  relation  to  age,  sex,  and  race,  and  discussed  in  an  enlightened  manner 
the  relation  of  various  diseases  and  disease  groups  to  the  annual  mortality. 

Crude  mortality-rates  for  deaths  from  all  causes  appear  annually  in  the 
reports  since  1875.  In  this  year,  Commissioner  Steuart  compared  the  rates  for 
Baltimore  with  those  of  some  40  other  cities,  and  in  1879  he  compiled  a  table 
of  the  annual  mortality  rates  for  1873  to  1879  and  discussed  some  of  the  chief 
contributory  factors.  However,  in  these  discussions,  as  well  as  those  of  succeed¬ 
ing  years  until  1916,  with  certain  notable  exceptions  to  be  reviewed  later, 
reported  cases  and  deaths  of  particular  diseases  were  recorded  only  in  absolute 
figures  and  not  in  relation  to  numbers  actually  exposed. 

From  1883,  the  reports  abound  in  statistical  tables  of  the  causes  of  death. 
The  earliest  gives  annually  from  1830  to  1883  the  total  deaths  from  all  causes, 
total  deaths  under  5  years  of  age,  and  the  total  deaths  from  “  zymotic  diseases,” 
with  the  percentage  of  deaths  of  children  under  5  years  to  the  total  deaths. 
In  1884,  tables  were  introduced  giving  the  total  number  of  deaths  by  months 
in  each  ward;  the  weekly  deaths  from  pulmonary  tuberculosis  by  color  and 
sex  from  1875;  the  annual  mortality  rates  from  all  causes  and  from  pulmonary 


196  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

tuberculosis,  according  to  race  (white  and  colored)  and  sex  from  1875  to  1884, 
with  the  mean  temperature  and  humidity  of  the  atmosphere;  a  comparative 
table  of  the  deaths  from  all  causes  and  for  pulmonary  tuberculosis  among 
males  and  females,  white  and  colored  for  the  10-year  period;  tables  of  the 
number  of  deaths  in  each  ward  for  each  week  in  1884  from  pneumonia,  pul¬ 
monary  tuberculosis,  and  from  the  various  “  zymotic  diseases.” 

In  the  next  year  these  tables  were  supplemented  by  one  giving  the  number 
of  deaths  from  cancer  from  1830  to  1884,  inclusive.  Additional  tables  were 
presented  in  1886  and  in  the  years  immediately  succeeding,  giving  the  annual 
number  of  deaths  since  1875  from  typhoid  fever  as  occurring  among  males, 
females,  native  and  foreign  white,  and  colored;  the  number  of  deaths  from  25 
“  zymotic  99  diseases  in  each  ward  by  months ;  the  total  number  of  deaths  in 
each  ward,  according  to  sex,  nativity,  and  race;  and  the  deaths  by  occupation 
of  the  decedents. 

The  report  for  1888  carried  an  interesting  chart,  giving  annually  the  number 
of  deaths  from  cholera  infantum  in  children  under  5  years  of  age  from  1830 
to  1888,  inclusive,  and  a  similar  one  for  scarlet  fever  and  for  small-pox.  In 
this  year  the  commissioner  of  health,  reviewing  the  mortality  from  “  zymotic  99 
diseases,  pointed  out  that  the  percentage  of  deaths  from  these  diseases  to  the 
total  mortality  from  all  causes  had  fallen  from  the  average  of  28  per  cent 
during  the  48  years  from  1836  to  1883  to  an  average  of  22  per  cent  for  the 
5-year  period,  1884  to  1888.  For  certain  specific  diseases,  the  drop  in  the 
average  annual  number  of  deaths  was  as  follows :  Scarlet  fever  from  227  to  57 ; 
diphtheria  (14  years  from  1870  to  1883)  from  469  to  143;  typhoid  fever  (24 
years  from  1860  to  1883)  from  190  to  155.  These  or  similar  tables,  in  which 
total  mortality  or  mortality  from  separate  diseases  or  disease  groups  are  com¬ 
pared,  almost  invariably  in  absolute  figures  of  the  numbers  of  deaths,  are 
features  of  the  health  department  reports  to  the  present  day. 

Since  1903,  the  reports  have  been  supplemented  by  other  raw-data  tables, 
dealing  with  diphtheria,  scarlet  fever,  measles,  whooping-cough,  gastro-enteritis 
in  children,  lobar-  and  broncho-pneumonia  and  bronchitis,  pulmonary  and  other 
forms  of  tuberculosis,  chronic  nephritis,  organic  diseases  of  the  heart,  and 
cancer.  In  these  tables  are  given  the  absolute  number  of  deaths,  mostly 
by  age,  sex,  color,  occupation,  and  ward,  but,  since  for  any  particular  disease, 
the  data  are  distributed  over  at  least  three  tables  and  arranged  in  each 
separate  table  in  relation  to  only  two  or  at  most  three  categories,  the  material 
is  relatively  useless  for  comparative  study.  From  some  of  these  tables,  however, 
it  is  possible  to  arrange  new  tables  from  which  there  may  be  calculated,  for  the 
census  year  1910,  rates  specific  in  regard  to  age,  sex,  and  color,  for  certain 
affections. 

Between  1903  and  1915,  Dr.  C.  Hampson  Jones  made  interesting  compara¬ 
tive  studies,  using  sometimes  rates  and  sometimes  absolute  figures,  of  certain 
principal  causes  of  death,  notably  of  tuberculosis,  typhoid  fever,  pneumonia, 
diarrhoea  and  enteritis  in  children,  Bright’s  disease,  and  organic  heart  disease, 
in  relation  to  age,  sex,  and  color. 

In  the  annual  summary  of  vital  statistics,  which  for  many  years  has  been 
given  in  connection  with  the  mortality  tables,  only  the  births  and  total  deaths 
are  expressed  in  rates,  the  deaths  from  prominent  communicable  and  other 
important  affections  being  given  only  in  absolute  figures. 


POPULATION  AND  STATISTICAL  DATA 


197 


RECORDS  OF  MORBIDITY. 

Records  of  morbidity  are  scanty  and  incomplete  before  1898.  In  years  of 
severe  epidemics  of  yellow  fever,  cholera,  and  small-pox,  some  reports  of  the 
number  and  distribution  of  cases  were  obtained,  but  it  is  doubtful  if  these  were 
ever  complete.  Quinan  chronicled  the  figures  for  cases  of  small-pox  during 
some  of  the  early  epidemics.  In  the  reports  of  the  consulting  physician,  or  of 
the  president  of  the  board  of  health,  in  the  earlier  years,  the  absence  or  presence 
of  cases  of  small-pox,  of  cholera,  or  of  .yellow  fever  are  often  noted.  Even  in 
the  extensive  epidemic  of  small-pox  in  1872-1873,  though  cases  were  searched 
out  by  the  police  and  health  wardens,  and  physicians  reported  cases  voluntarily, 
the  annual  reports  fail  to  record  the  number  of  cases.  In  the  report  for  1882 
it  is  stated  that  4,000  cases  of  small-pox  were  discovered  in  1872,  and  that 
probably  an  equal  number  of  cases  were  concealed.  It  can  not  be  said  that 
there  were  any  morbidity  statistics,  even  for  small-pox,  in  the  Baltimore  health 
department  until  1882.  Not  until  after  1894  was  there  any  serious  effort  made 
to  record  data  for  and  to  utilize  morbidity  statistics  in  the  health  department. 
Between  1898  and  1915,  Dr.  Jones  used  morbidity  data  in  the  study  of  typhoid 
fever,  and  Dr.  Stokes,  in  his  annual  reports,  used  morbidity  rates  in  his  studies 
of  the  influence  of  diphtheria  antitoxin  and  the  diphtheria-culture  test  upon 
the  prevalence  of  diphtheria,  and  of  the  relation  of  water  and  milk  to  typhoid 
fever.  It  can  not  be  said,  however,  that  before  1916  any  attempt  was  made 
to  apply  data  of  morbidity  routinely  to  problems  of  public-health  administra¬ 
tion  in  Baltimore. 

The  reporting  of  communicable  diseases,  with  the  exception  of  pulmonary 
tuberculosis,  measles,  mumps,  and  whooping-cough,  has  been  fairly  full  and 
accurate  since  1898,  and  the  data  for  all  of  the  reportable  diseases  has  been 
compiled  by  weeks  and  months  since  this  date. 

The  annual  reports  of  the  quarantine  officer,  since  1832,  contain  tables  giving 
the  numbers  of  cases  and  deaths  at  the  station.  Many  of  these  included,  of 
course,  individuals  sent  from  the  city  ill  with  small-pox  and  typhus  fever. 

The  extensive  tables  of  defects  found  in  routine  examinations  of  school 
children  by  the  medical  inspectors  and  published  annually  since  1907  present 
the  data  in  absolute  figures  only. 

STATISTICAL  METHOD. 

Unless  indicated  otherwise,  all  rates  for  natality,  mortality,  and  morbidity 
presented  in  this  work  are  calculated  on  the  basis  of  100,000  living  population. 
Decimal  fractions  5  and  over  have  been  absorbed  by  the  whole  number  and  those 
below  5  have  been  disregarded.  As  they  are  commonly  without  significance, 
with  few  exceptions,  rates  amounting  to  less  than  1  per  100,000  have  not  been 
entered  iu  the  statistical  tables.  For  convenience  in  typography,  the  initial 
letters  C,  D,  and  R  are  used  to  signify  the  words  case,  death,  and  rate  in  the 
tables  of  morbidity  and  mortality.  Rates  for  the  total  population  and  those 
specific  for  color  and  sex  are  calculated  on  the  populations  in  table  12,  and 
those  specific  for  age,  color,  and  sex  on  the  populations  in  tables  10  and  11. 
Certain  rates  for  deaths  under  1  year  and  for  maternal  morbidity  are  based 
on  data  of  table  14.  Unless  otherwise  indicated,  the  rubric  numbers  referred  to 
in  the  text  are  those  of  the  international  classification  of  the  Causes  of  Death, 
revision  of  1909. 


PART  V.— THE  FEBRILE  DISEASES. 
Chapter  X. — Nuisance  Diseases. 


1.  Insect-borne  diseases:  Malaria;  Yellow  fever;  Typhus  fever.  (Tables 
16,  18,  graphs  2-4.) 

2.  Acute  inflammatory  affections  of  the  intestinal  tract  characterized 
by  frequent  loose  stools  of  abnormal  composition:  Diarrhoea;  Dysentery; 
Asiatic  cholera;  Typhoid  fever.  (Tables  19  to  33,  graphs  5  to  10.) 

INSECT-BOENE  DISEASES. 

Of  the  diseases  spread  from  man  to  man  through  the  media  of  biting  or 
stinging  insect  hosts  as  vectors,  malarial,  yellow,  and  typhus  fevers  are  the 
only  ones  of  practical  importance  in  Baltimore.  Only  one  death,  in  1879,  has 
been  recorded  from  relapsing  fever,  and  bubonic  pest,  trypanosomiasis,  and 
other  diseases  of  this  class  have  never  been  recognized  in  Baltimore. 

MALARIAL  FEVERS. 

Malaria  was  common  in  Maryland  for  many  years  before  Baltimore  was 
founded,  but  very  little  information  exists  concerning  the  prevalence  and 
severity  of  the  malarial  diseases  in  Baltimore  Town  before  1794,  and  then  they 
are  mentioned  only  incidentally  in  connection  with  yellow  fever  as  perennially 
present,  in  varying  intensity  in  the  summer  and  fall,  particularly  along  the 
water-front,  and  especially  at  FelFs  Point.  Davidge,  Reese,  Coulter,  Potter, 
and  others  in  their  reports  and  other  writings  on  yellow  fever,  between  1798 
and  1821,  constantly  referred  to  the  “  common  intermittent,  remittent,  and 
bilious  remittent  fevers,”  associated  often  with  dysentery  and  present  every 
year  at  FelPs  Point  and  along  Jones  Falls.  They  attributed  these  fevers  to 
noxious  vapors  arising  from  decaying  vegetable  material  in  the  numerous 
ditches,  ponds,  pools,  and  dock-slips  at  FelFs  Point  and  in  the  basin  and  in 
the  marshes  along  the  latter  and  Jones  Falls  and  Harford  Run. 

These  annual  summer  and  fall  fevers,  either  intermittent  or  remittent  in 
type,  varied  much  in  severity  not  only  from  year  to  year  but  in  any  particular 
season,  and  were  described  as  being  of  a  much  more  severe  type  in  the  late 
summer  and  early  fall  than  in  June,  when  they  made  their  first  appearance. 
Yellow  discoloration  of  the  skin  and  vomiting  of  bile  (or  broken-down  blood 
mistaken  for  bile)  were  common  characteristics  of  the  remittent  form  so  com¬ 
monly  termed  “  bilious  fever.”  These  characteristics  caused  this  type  of 
malarial  fever  to  be  confused  in  certain  years  with  true  yellow  fever,  which 
even  so  good  an  observer  as  Davidge  held  to  be  only  an  accentuation  of  the 
familiar  bilious  remittent.  From  the  descriptions  of  the  intermittent  and  of 
the  usual  remittent  fevers,  as  well  as  from  their  successful  treatment  with 
preparations  of  cinchona  bark,  it  is  fair  to  conclude  that  these  fevers  were  for 
the  most  part  true  malaria.  That  bilious  or  bilious  remittent  fever  was  a 
synonym  for  remittent  malarial  fever  appears  certain  from  the  writings  of 
Davidge,  Potter,  Bartlett  (48),  and  Jameson  (49).  The  latter  described  an 
epidemic  of  bilious  remittent  fever,  occurring  in  1804,  that  was  successfully 
curbed  by  treatment  with  “  the  bark.” 


199 


200  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

The  great  expansion  of  ocean  commerce  between  Baltimore  and  the  West 
Indies,  after  the  Revolutionary  War,  and  later  with  the  Southern  States  and 
with  South  America,  must  have  insured  the  annual  importation  of  cases  of 
the  severer  grades  of  tropical  and  subtropical  malaria,  from  which  infection 
was  spread  by  mosquitoes  abounding  at  Fell’s  Point  and  the  lower-lying 
sections  about  the  basin  and  the  streams  flowing  into  it.  The  topography  of 
the  city  and  the  imperfect  drainage,  due  to  the  poor  grading,  pavements,  and 
gutters,  afforded  abundant  opportunities  for  large  and  small  mosquito-breeding 
pools.  The  standing  water  in  many  cellars  furnished  another  set  of  breeding 
places.  According  to  the  annual  health  report  for  1824,  there  was  a  marked 
decrease  in  autumnal  sickness  in  the  neighborhood  of  Eden  Street  and  Harford 
Run  after  filling  in  and  running  a  drain  which  did  away  with  standing  water, 
and  it  was  noted  that  the  “  French  drains  ”  constructed  in  various  parts  of 
FelPs  Point  acted  well  and  the  inhabitants  suffered  much  less  with  autumnal 
fever  than  in  the  preceding  fall. 

In  his  work  on  epidemic  cholera  at  the  Baltimore  almshouse  in  1849,  Thomas 
H.  Buckler  (11)  gave  a  map  (2)  of  the  medical  topography  of  Baltimore  in 
1851,  on  which  the  whole  territory  south  and  southeast  and  west  of  the  city 
bordering  on  the  Patapsco  River,  Curtis  Bay,  and  the  middle  branch  is  marked 
“  Region  of  intermittent  and  remittent  fever.”  The  northern  limit  of  this  area 
was  bounded  by  the  “  mine  banks,”  or  iron-ore  deposits ;  on  the  west  side  it 
followed  the  general  course  of  the  Baltimore  and  Ohio  Railroad,  and  on  the  east 
side  the  Philadelphia  Turnpike,  just  north  of  the  Baltimore,  Wilmington,  and 
Philadelphia  Railroad.  At  the  almshouse,  situated  to  the  west  of  the  northern 
border  of  the  city,  “  intermittent  and  remittent  bilious  fevers  were  spontaneous 
in  their  origin  (among  the  inmates)  almost  every  season,  while  the  country  for 
a  mile  or  two  around  enjoyed  a  comparative  immunity  from  these  affections. 
Besides  the  indigenous  origin  of  malarious  fevers,  a  very  large  number  of  inter- 
mittents  are  brought  in  every  season,  and  also  remittents,  in  the  autumn  of 
some  years,  from  the  iron-ore  mine-banks,  of  the  Washington  and  Philadelphia 
Roads.”  That  the  remittent  fever  of  this  period  at  the  almshouse  was  continuous 
malarial  fever  is  attested  by  the  notes  of  William  T.  Howard,  sr.,  a  medical 
resident  there  in  1843,  in  which  was  recorded  a  clear-cut  clinical  history  of  a 
fatal  case  with  a  full  autopsy  protocol  of  a  man  from  the  “  mine  bank.”  This 
case  was  also  reported  by  Swett  (50)  of  Hew  York.  Anderson  and  Prick  (51), 
resident  physicians  at  the  almshouse  during  the  summer  of  1844,  autopsied  12 
cases  of  remittent  fever,  which  were  analyzed  by  Alfred  Stille  in  1845.  Ten 
of  these  12  cases  came  from  the  mine-banks.  Buckler  recorded  that  in  1851  a 
grave  epidemic  of  intermittent  and  remittent  fevers  prevailed,  as  a  new  feature 
of  the  medical  history  of  this  locality,  on  both  sides  of  Jones  Falls,  north  of 
Centre  Street,  and  at  the  Maryland  Penitentiary.  The  outbreak  of  malarial 
fevers  in  this  locality  was  attributed  by  Buckler  to  the  vast  quantities  of  filth 
in  the  bed  of  the  falls,  the  stream  of  which  was  rendered  sluggish  in  the  dry 
season  by  the  diversion  of  so  large  a  proportion  of  its  water  to  supply  the 
reservoir,  situated  above  at  the  Belvedere  Bridge.  That  malarial  fevers  were 
rife  between  1870  and  1885  at  Fell’s  Point  and  along  the  uncovered  portions 
of  Harford  Run,  in  the  northwestern  section  of  the  city,  is  evident  from  the 
text  of  the  reports  of  the  commissioners  of  health.  Dr.  Alexander  C.  Abbott 
is  authority  for  the  statement  that  in  the  latter  area  between  1870  and  1880 


FEBRILE  DISEASES 


201 


large  numbers  of  newly  built  houses  were  vacated  by  their  tenants  because  of 
the  great  prevalence  of  severe  malarial  fever.  Between  1889  and  1895,  many 
individuals  with  malaria  living  in  various  parts  of  the  city,  and  from  the 
surrounding  territory  on  or  near  the  water,  particularly  at  Sparrow’s  Point, 
applied  to  the  dispensaries  of  the  Maryland  University  and  Johns  Hopkins 
Hospital.  At  Bayview  Asylum  the  experience  of  the  former  almshouse  was 
repeated  between  1866  and  1900. 

There  is  no  doubt  that  from  its  early  history  until  about  1895  malarial 
fevers  were  very  prevalent  in  and  around  Baltimore;  within  the  city  its  chief 
prevalence  was  about  the  harbor,  docks,  basin,  Jones  Falls,  Harford  Run,  and 
probably  along  the  courses  of  Schroeder’s  and  Chatworth’s  Runs.  In  these 
portions  of  the  city  conditions  were  particularly  favorable  for  mosquito  breeding, 
not  only  because  of  standing  water  in  and  about  docks,  in  streams  and  marshes, 
and  in  the  streets,  gutters,  alleys,  and  yards  of  low-lying  valleys,  but  in  cellars. 
Much  malaria  was  doubtless  imported  from  the  Southern  States  and  the  West 


Table  16. 


Year. 

No.  of 
specimens. 

No.  of 
positive 
specimens. 

Year. 

No.  of 
specimens. 

No.  of 
positive 
specimens. 

1903  . 

272 

4 

1912  . 

513 

52 

1904  . 

308 

2 

1913  . 

746 

5 

1905  . 

406 

2 

1914  . 

437 

4 

1906  . 

587 

11 

1915  . 

417 

4 

1907  . 

526 

17 

1916  . 

476 

3 

1908  . 

491 

6 

1917  . 

247 

1 

1909  . 

371 

1 

1918  . 

79 

1 

1910  . 

497 

1 

1919  . 

60 

1 

1911  . 

507 

17 

1920  . 

48 

1 

Indies  and  South  America  and  from  rural  districts  of  tidewater  Maryland  and 
Virginia,  particularly  by  summer  visitors  from  the  city. 

The  reports  of  the  quarantine  officers  show  that  malaria  in  fatal  form  not 
infrequently  attacked  those  ill  with  small-pox  or  typhus  fever  sent  from  the 
city  to  the  old  Marine  Hospital,  particularly  in  the  fifth  and  sixth  decades  of 
the  nineteenth  century.  At  this  period  many  cases  of  severe  malaria  were  taken 
from  vessels  from  southern  ports,  including  Central  America.  Malaria  was  so 
prevalent  at  the  quarantine  station  that  for  many  years,  and  until  at  least  1890, 
the  officers  and  employees  were  regularly  dosed  with  quinine  in  whisky. 

The  decrease  in  the  number  of  deaths  from  malarial  diseases  since  1900 
has  been  associated  with  a  decrease  in  the  number  of  recognized  cases  in  dis¬ 
pensary  and  hospital  practice  and  in  the  experience  of  leading  clinicians.  The 
figures  of  examinations  of  blood  for  diagnosis  in  the  bacteriological  laboratory 
since  1903  are  shown  in  table  16.  From  table  16  it  is  evident  that  until  1918 
malaria  was  frequently  suspected  by  physicians.  The  percentage  of  cases  in 
which  the  tentative  diagnosis  was  confirmed  was  relatively  small.  It  was  2.5 
per  cent  between  1903  and  1912,  and  0.8  per  cent  between  1913  and  1920. 
In  the  first  period  there  were  two  well-marked  minor  epidemics,  each  covering 
a  period  of  two  years. 


202  PUBLIC  HEALTH  ADMINISTRATION",  ETC.,  IN  BALTIMORE 

Deaths  from  malarial  fevers  have  been  classified  in  the  annual  reports  under 
six  headings:  (1)  intermittent  fever,  (2)  remittent  fever,  (3)  bilious  fever, 
(4)  congestive  fever,  (5)  malarial  fever,  and  (6)  typho-malarial  fever.  This 
classification  has  been  influenced  by  variations  in  fashion  in  both  medical  and 
statistical  nosology.  The  absolute  figures  and  the  rates  (except  for  typho- 
malarial  fever,  omitted  for  reasons  given  later)  are  set  forth  in  table  17.  From 
a  study  of  these,  in  connection  with  graph  2,  an  approximate  idea  of  the  course 
of  malarial  fevers  in  Baltimore  is  attained.  It  is  evident  that  intermittent 
fever  is  the  only  variety  that  can  be  followed  continuously  throughout  the  series 
of  years.  With  the  exception  of  1816,  from  1815  until  1909,  it  appears  each 
year  as  a  cause  of  death.  This  form  of  malaria,  on  account  of  the  characteristic 
paroxysms  of  chill,  fever,  and  sweating,  occurring  usually  at  regular  intervals 
measured  in  days,  with  its  afebrile  intermissions,  was  relatively  easy  of 
diagnosis,  and,  of  the  group  of  malarial  diseases,  the  one  least  likely  to  be  con¬ 
fused  with  other  febrile  affections,  malarial  and  non-malarial,  and  for  these 
reasons  the  figures  and  rates  for  this  disease  may  be  regarded  as  a  fairly  close 
approximation  to  the  truth. 

Attention  is  directed  to  the  fact  that  intermittent  fever  has  been  a  factor  of 
considerable  weight  in  the  death-rate,  in  one  year  (1821)  having  a  rate  of  30 
and  in  2  years  (1871  and  1872)  surpassing  this  figure,  while  in  a  number  of 
years  (1821,  1822,  1829,  1834,  1837,  1842,  1864,  1867,  1868,  1869,  1870, 
1871,  1872,  1873,  and  1874)  its  rate  was  over  10. 

The  peaks  in  the  curve  for  intermittent  fever  follow  rather  closely,  but  not 
exactly,  those  of  the  curves  for  bilious  fever  and  for  the  total  of  the  malarial 
diseases.  With  the  exception  of  1820,  when  there  were  24  deaths  recorded  under 
this  heading  (with  a  rate  of  41),  remittent  fever  has  not  been  credited  with  any 
large  contributions  to  the  malarial  deaths  in  Baltimore. 

To  bilious  fever,  the  old  synonym  for  continuous  or  remittent  fevers,  in 
contrast  to  intermittent  malarial  fevers,  the  great  bulk  of  the  deaths  ascribed 
to  malaria  were  assigned  from  the  beginning  of  our  records  until  1875.  In  the 
latter  year  (the  date,  by  the  way,  of  the  first  use  in  Baltimore  of  death  certifi¬ 
cates  signed  by  physicians)  it  practically  dropped  out  of  the  local  statistical 
nosology,  the  deaths  which  previously  would  have  been  so  ascribed  being  from 
this  date  classed  under  malaria  and  remittent  fever.  A  few  deaths,  however, 
were  thus  classified  as  late  as  1885.  The  number  of  deaths  attributed  to  bilious 
fever  in  the  earlier  years,  say  between  1812  and  1819,  inclusive,  is  greater  than 
that  attributed  to  any  other  single  cause  affecting  all  ages,  with  the  exception 
of  consumption.  During  these  8  years,  the  deaths  from  the  former  averaged 
about  12  per  cent,  and  those  from  the  latter  about  17  per  cent  of  the  total 
deaths  from  all  causes.  It  is  certain  that  before  1851,  and  probably  after  that 
date,  deaths  from  various  causes  other  than  severe  continued  malarial  fever 
were  classed  under  bilious  fever.  In  the  first  place,  owing  to  the  belief  so 
firmly  held  in  the  early  part  of  the  nineteenth  century  by  certain  Baltimore 
physicians  that  yellow  fever  was  an  accentuated  form  of  continued  malarial 
fever,  it  is  extremely  probable  that  not  only  in  years  of  clearly  recognized 
epidemics  of  yellow  fever,  but  in  other  years,  at  least  until  1875  some  cases  of 
true  yellow  fever,  perhaps  in  atypical  form,  were  called  bilious  fever.  It  is 
probable,  indeed,  that  in  severe  cases,  and  particularly  when  fatal,  the  diagnosis 
between  yellow  and  bilious  remittent  malarial  fever  was  difficult,  or  even 


FEBRILE  DISEASES 


203 


impossible.  In  the  second  place,  as  recorded  by  Davidge,  dysentery,  which  so 
often  occurred  in  the  same  individual  concurrently  with  malaria  and  was  by 
many  believed  to  be  a  part  of  the  malarial  process,  may  have  swollen  the  bilious- 
fever  death-list.  In  the  third  place,  it  is  likely  that  until  1850  and  for  years 
after,  bilious  fever  shared  with  remittent  fever,  diarrhoea,  and  inflammation 
of  the  bowels  as  classification  categories  for  typhoid  fever.  In  the  fourth  place, 
it  is  not  unlikely  that  during  the  early  period  some  of  the  deaths  from  other 
severe  affections  characterized  by  high  fever  of  a  remittent  type,  such  as  acute 
endocarditis,  pyemia,  septicemia,  and  even  typhus  fever,  were  assigned  to 
bilious  fever.  On  the  other  hand,  the  leading  physicians,  Drs.  Allenby,  Coulter, 
and  W.  H.  and  W.  A.  Clendenin,  in  practice  at  Fell's  Point,  the  chief  home 
within  the  city  of  bilious  fever,  were  men  of  ability  and  discernment. 

Deaths  classed  under  congestive  fever  are  considered  to  have  been  due  to 
that  acute  form  of  virulent  malaria  characterized  by  severe  chill,  very  high 
fever,  delirium,  coma,  a  prostration  comparable  to  that  of  surgical  shock,  and 
by  massive  infection  (often  particularly  marked  in  the  cerebral  capillaries) 
by  malarial  organisms  of  the  aestivo-autumnal  type.  Synonymous  with  the 
dreaded  “  congestive  chills  ”  and  the  pernicious  malarial  fever  of  the  Southern 
States  and  the  tropics,  appearing  in  the  local  statistical  nosology  first  in  1836,  it 
was  credited  with  death  in  every  year  (with  the  exception  of  1848,  1855  to  1860, 
1862,  and  1876)  until  1884.  Its  most  conspicuous  part  was  played  between 
1870  and  1874  (with  death-rates  above  10  in  1871-1873)  towards  the  end  of 
the  great  wave  of  malaria  beginning  in  1862  and  ending  abruptly  in  1875. 

The  term  malaria  first  appeared  in  the  local  statistical  nosology  in  1877,  and 
disappeared  in  1902  to  reappear  from  1910  to  1920.  As  is  clear  from  table  17, 
it  was  used  indiscriminately  for  the  other  nosology  categories  applying  to 
malarial  affections.  Its  curve  follows  closely  that  of  deaths  for  all  forms  of 
malaria. 

Typho-malarial  fever  made  its  first  appearance  among  the  causes  of  death 
in  the  Baltimore  health  reports  in  1876,  with  32  deaths.  With  the  exception 
of  the  following  2  years,  it  was  credited  with  deaths  until  1898.  During  this 
period,  the  number  of  deaths  assigned  to  this  cause  varied  from  12  in  the 
latter  year  to  75  in  1885.  It  is  impossible  to  determine  what  proportion  of  the 
deaths  recorded  under  this  category  was  due  to  typhoid  fever  alone,  to  malaria 
alone,  to  a  combination  of  these  two  diseases,  to  malaria  and  other  diseases,  or 
to  other  diseases  without  malaria.  That  typhoid  fever  and  malaria  may  exist 
in  the  same  individual  has  long  been  clearly  established,  and  is  quite  likely 
that,  when  in  combination,  an  attack  of  typhoid  fever,  from  which  recovery 
would  otherwise  have  occurred,  might  be  determined  to  a  fatal  issue- by  the 
complicating  malaria.  Further,  it  is  probable  that  in  Baltimore  typhoid  fever 
not  infrequently  attacked  individuals  who  were  the  subjects  of  chronic  or  latent 
malaria,  and  that,  in  this  case,  just  as  is  known  to  happen  in  the  course  of 
pneumonia.,  fractures,  and  other  pathological  conditions,  the  dormant  malarial 
infection  may  show  an  exacerbation.  With  all  these  considerations  in  view,  it 
has  seemed,  on  the  whole,  wiser  to  omit  the  deaths  ascribed  to  typho-malaria 
from  consideration  here  and  to  include  them  with  typhoid  fever. 

When  the  curve  for  malaria  as  a  whole  is  reviewed  (graph  2),  two  points 
stand  out  conspicuous^,  its  shape  and  height.  The  curve  of  the  annual  rates 
for  total  deaths  is  divided  into  four  large  waves,  the  first  and  highest  beginning 
14 


204 


PUBLIC  HEALTH  ADMINISTKATION,  ETC.,  IN  BALTIMOBE 


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IN  BALTIMORE 


PUBLIC  HEALTH  ADMINISTRATION,  ETC., 


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FEBRILE  DISEASES 


207 


before  1812,  reaching  its  peak  in  1822  with  the  extraordinary  rate  of  589  and 
its  low  point  in  1838  with  a  rate  of  41;  the  second  and  much  lower  wave  cul¬ 
minating  in  1862  with  its  highest  peak,  a  rate  of  69,  in  1842 ;  the  third,  showing 
at  its  peak  in  1871  a  rate  of  72  and  ending  in  1877  with  a  rate  of  9,  the  lowest 
in  the  city’s  history;  and  the  fourth,  beginning  in  1878,  rising  gradually  to  a 
rate  of  28  in  1881  and  falling  by  gradual  stages  to  a  negligible  value  in  1915. 

The  first  two  waves  possess  striking  characteristics  which  are  lacking  in  the 
last  two,  namely,  multiple  subsidiary  peaks  and  depressions  of  great  height  and 
depth,  and,  during  the  years  covered  by  them — 1812  to  1862 — bilious  fever  is 
the  great  contributory  element,  the  curve  for  this  cause  being  almost  as  high 
as  that  for  the  total  for  malarial  diseases,  with  which  it  closely  conforms.  In 


Graph  2  (fiom  table  17).  Annual  crude  mortality  rates  from  insect-borne 

diseases,  1812  to  1920,  inclusive. 


the  first  great  wave  the  peaks  of  the  subsidiary  waves  are  separated  by  intervals 
of  from  1  to  4  years.  Between  the  extraordinarily  high  peak  of  1822  and  the 
next  one  in  1826  there  is  an  interval  of  4  years,  the  rate  for  1824,  the  mid-year, 
falling  from  589  to  101.  The  time  intervals  between  the  subsidiary  peaks  and 
depressions  of  the  second  great  wave  are  about  the  same  as  those  of  the  first, 
but  the  peaks  are  without  exception  all  lower  than  the  depressions  of  the 
first  great  wave.  In  both  the  first  and  second  waves  a  straight  line  would 
almost  connect  the  points  marking  the  rates  for  the  years  of  depression,  and 
the  slant  of  the  line  in  each  instance  would  be  acute,  much  more  so,  however, 
for  the  low  points  of  the  first  than  of  the  second  wave.  With  the  ending  of  the 
second  wave,  malaria,  as  a  cause  of  death  in  Baltimore,  had  come  to  play  a 
comparatively  subsidiary  role.  Thus,  these  two  waves  are  characterized  by 
multiple  epidemics  of  fatal  malarial  fever,  in  which  the  remittent  type — now 


208  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


called  sestivo-autumnal — commonly  classified  as  bilious,  but  sometimes  as  remit¬ 
tent  (1819-1821,  1824,  1844,  1845,  1848-1850)  and  sometimes  as  congestive 
(1836-1847,  1850-1854),  played  overwhelmingly  the  principal  role.  When  the 
rates  for  all  forms  of  malaria  are  averaged  for  5-year  periods  (table  18,  graph  3) 
the  course  of  the  disease  may  be  followed  wdth  greater  ease.  From  a  level  of 
211  for  the  period  ending  in  1815,  the  rate  fell  to  141  in  1816-1820  and  rose 
to  264  in  1821-1825.  From  the  highest  point  the  rate  fell  continuously  but  by 
somewhat  uneven  gradations  to  23  in  1856-1860.  Eemaining  stationary  during 
the  Civil  War  period,  the  rate  rose  during  the  next  decade  to  52  in  1871-1875. 


Table  18. — Average  rate  of  death  by  5-  and  10-year  periods  from  insect-borne  diseases , 

from  1812  to  1920,  inclusive. 


Period. 

Malarial  fever. 

Yellow 

fever. 

Malarial  and 
yellow  fever. 

Typhus  fever. 

Total. 

By  5-year 
periods. 

By  10-year 
periods. 

By  5-year 
periods. 

By  10-year 
periods. 

By  5-year 
periods. 

By  10-year 

periods. 

By  5-year 

periods. 

By  10-year 

periods. 

By  5-year 

periods. 

By  10-year 

periods. 

I 

1812-15... 

211 

•  •  •  • 

•  •  •  • 

211 

•  •  •  • 

77 

•  •  •  • 

288 

•  •  •  • 

1816-20.. . 

141 

172 

126 

70 

267 

242 

109 

95 

376 

337 

1821-25... 

264 

•  •  •  • 

1 

•  •  •  • 

265 

•  •  •  • 

116 

•  •  •  • 

381 

1826-30.. . 

104 

184 

1 

104 

185 

41 

78 

145 

263 

1831-35... 

95 

•  •  •  • 

•  •  •  • 

95 

•  •  •  • 

37 

•  •  •  • 

132 

•  •  •  • 

1836-40.. . 

52 

74 

•  •  •  • 

52 

74 

22 

29 

74 

103 

1841-45... 

47 

•  •  •  • 

•  •  •  • 

47 

•  •  •  • 

12 

•  •  •  • 

59 

•  •  •  • 

1846-50... 

42 

44 

•  •  •  • 

42 

44 

64 

38 

106 

83 

1851-55... 

40 

•  *  •  • 

6 

•  •  •  • 

46 

•  •  •  • 

10 

•  •  •  • 

55 

•  •  •  • 

1856-60... 

23 

32 

3 

23 

35 

2 

6 

26 

41 

1861-65... 

23 

•  •  •  • 

•  •  •  • 

23 

•  •  •  • 

1 

0  0  0  0 

24 

•  •  •  • 

1866-70... 

34 

29 

2 

1 

36 

30 

5 

3 

41 

32 

1871-75... 

52 

•  •  •  • 

•  •  •  • 

52 

•  •  •  • 

4 

0  0  0  0 

56 

•  •  •  • 

1876-80... 

15 

34 

3 

1 

18 

35 

2 

3 

20 

38 

1881-85... 

26 

•  •  •  • 

•  •  •  • 

26 

•  •  •  • 

•  •  •  • 

•  •  •  • 

26 

•  •  •  • 

1886-90... 

19 

22 

•  •  •  • 

19 

22 

•  •  •  • 

19 

22 

1891-95... 

11 

•  •  •  • 

•  •  •  • 

11 

•  •  •  • 

•  •  •  • 

11 

•  •  •  • 

1896-1900. 

9 

10 

0  0  0  0 

9 

10 

•  •  •  • 

9 

10 

1901-05.. . 

4 

•  •  •  • 

0  0  0  0 

4 

•  •  •  • 

•  •  •  • 

4 

•  •  •  • 

1906-10.. . 

2 

3 

0  0  0  0 

2 

3 

•  •  •  • 

2 

3 

1911-15... 

1 

•  •  •  • 

0  0  0  0 

1 

•  •  •  • 

•  •  •  • 

1 

•  •  •  • 

1916-20... 

•  •  •  • 

1 

0  0  0  0 

0  0  0  0 

1 

0  0  0  0 

•  •  •  • 

•  •  •  • 

1 

The  drop  in  the  rate  to  15  in  1876-1880  was  succeeded  by  a  rise  to  26  in 
1881-1885.  From  this  date  the  rate  declined  uninterruptedly  to  the  vanishing- 
point  in  1916-1920.  When  the  rates  are  averaged  for  10-year  periods  (graph  4) 
the  course  of  the  curve  is  even  smoother. 

Assuming  that  the  absolute  figures  for  deaths  from  malaria  during  these 
periods  are  approximately  accurate,  from  the  information  at  hand,  how  may 
these  high  rates  and  their  fluctuations  during  these  two  periods  be  explained  ? 

The  first  wave  of  malaria,  evidently  well  on  its  ascent  before  the  present 
story  opens,  comes  under  observation  after  a  period  of  rapid  growth  due  to 
immigration  on  a  huge  scale  of  people  from  more  northern  climates  and  less 
inured  to  malarial  infection  to  a  crowded  little  city  situated  on  a  stagnant 
basin,  bisected  by  streams  sluggish  in  the  summer,  and  surrounded  by  marshes, 


FEBRILE  DISEASES 


209 


Graph  3  (from  table  18).  Crude  mortality  rates  from  insect-borne  diseases, 
averaged  by  5-year  periods,  from  1812  to  1920. 


Graph  4  (from  table  18).  Crude  mortality  rates  from  insect-borne  diseases, 
averaged  by  10-year  periods,  1812  to  1920. 


210  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

about  which  its  chief  industrial  life  was  centered.  For  over  20  years  previous 
this  community  had  carried  on  a  thriving  commerce  with  tropical  or  semi- 
tropical  ports,  and  this  trade  was  still  active  and  remained  so  for  many  years. 
Thus,  malaria  in  its  severest  forms  must  have  been  constantly  imported  to  be 
readily  spread  among  a  population  but  poorly  acclimated.  The  lower  parts, 
at  least,  of  the  city  abounded  in  stagnant  pools  and  ill-drained  streets,  yards, 
and  vacant  lots.  Two  reservoirs  at  the  upper  borders  of  the  city  furnished 
additional  breeding-places  for  mosquitoes.  Cinchona  bark,  on  account  of  the 
wars,  was  probably  too  scarce  and  too  high  in  price  to  be  available  for  a  large 
proportion  of  the  inhabitants. 

The  minor  epidemic  peaks  of  the  second  wave  were  perhaps  associated  with 
the  ultimate  killing  off  and  reaccumulation  of  susceptibles  (immigration  being 
largely  responsible  for  the  latter)  and  the  neglect  after  a  year  or  so  of  sanitary 
measures  inaugurated  during  the  epidemic  peaks. 

The  third  great  wave,  extending  over  the  15  years  between  1862  and  1877, 
differs  radically  from  its  two  predecessors.  Its  ascent  is  at  first  gradual  and 
broken  by  a  minor  wave  without  a  decided  peak  covering  the  last  3  years  of  the 
Civil  War  and  then  abrupt,  reaching  its  highest  level  in  1871.  From  this  point 
there  is  a  gradual  drop  during  the  3-year  period,  1872  to  1874.  In  1875  there 
is  a  marked  drop  to  14,  and  the  wave  culminates  in  1877  with  the  lowest  rate 
hitherto  attained.  The  intermittent  type  of  malarial  fever  now  makes  a  much 
more  decided  contribution  to’ the  total  rate  than  before,  and  its  curve  follows 
very  closely  that  of  the  total  curve.  The  curves  of  bilious  fever  and  of  con¬ 
gestive  fever,  the  two  elements  representing  continued  or  sestivo-autumnal " 
malarial  fever,  conform  very  closely  with  the  curves  of  the  total  malarial  rate 
and  with  the  rate  for  intermittent  fever.  Indeed,  were  the  rates  for  these  two 
types  combined,  the  resulting  curve  would  closely  fit  both  as  to  area  and  form  the 
curve  for  intermittent. 

The  decline  in  the  rate  for  continued  fever  and  the  consequent  comparatively 
low  total  rate  during  and  immediately  after  the  Civil  War  are  probably  directly 
associated  with  the  cutting  off  of  communications  of  Baltimore  from  the 
Southern  States,  the  West  Indies,  and  Central  and  South  America  during  this 
period,  and  the  subsequent  rise  in  the  death-rate  from  this  type  of  malaria  in 
the  succeeding  years  up  to  1871  and  1872,  may  well  be  intimately  associated 
with  the  assumption  of  relations  by  land  and  by  sea  with  these  sources  of  more 
virulent  malaria.  It  will  be  noted  that  during  the  Civil  War  there  was  a 
distinct,  though  not  very  great  rise  in  the  curve  for  intermittent  fever,  with  a 
subsidence  before  the  beginning  of  its  great  rise  to  rates  of  over  30  during  1871 
and  1872.  It  is  evident  that  the  restrictions  upon  civilian  intercourse  during 
the  Civil  War  more  than  counterbalanced  any  infection  of  the  city  by  troops. 
The  rise  in  the  rates  for  malarial  fevers  between  1866  and  1874  was  perhaps 
influenced  to  a  considerable  degree  by  the  large  immigration  of  unacclimatized 
people  from  Ireland  and  Germany.  Among  conditions  of  a  local  character 
favoring  the  fall  of  malarial  deaths  were  the  improvements  resulting  from  the 
draining  and  filling  at  Fell’s  Point  and  along  lower  Jones  Falls  and  Harford 
Run,  the  abandonment  of  the  Franklin  Street  and  Belvedere  Reservoirs,  and 
the  covering  over  of  Chatsworth’s  and  Schroeder’s  Runs. 

The  last  great  wave,  beginning  in  1878,  is  characterized  by  a  curve  that  rises 
almost  abruptly  to  its  highest  point  with  a  rate  of  28  in  1881  and  falls  very 


FEBRILE  DISEASES 


211 


gradually  with  a  few  minor  rises  (1893-1896  and  1897-1900),  disappearing 
almost  entirely  in  1915.  This  curve  is,  therefore,  relatively  smooth.  The  rate 
for  the  newly  introduced  rubric  malaria  is  the  chief  contributor  to  the  total 
rate,  and,  as  previously  explained,  this  term  must  include  deaths  from  both 
the  intermittent  and  the  continuous  types  of  malarial  fever.  It  will  be  noted 
that  with  the  decline  of  its  curve  from  1897  and  its  disappearance  from  the 
nosology  in  1902  the  curve  for  intermittent  fever  rises.  After  1910,  no  dis¬ 
tinction  was  made  between  continued  and  intermittent  fevers.  Bilious  fever 
contributes  a  small  quota  to  the  total  rate  until  1885,  and  remittent  fever  is 
responsible  for  a  considerable  contribution  thereto  until  1897.  To  what  factors 
is  the  course  of  the  malarial  curve  from  1877  to  be  attributed?  The  reasons 
for  the  rise  immediately  after  this  date  are  as  uncertain  as  are  those  for  its  fall 
immediately  before.  The  rise  and  the  peak  of  the  curve  coincide  with  the 
beginning  and  continuation  of  a  migration  from  southern  Europe,  i.  e.,  Bohemia 
and  Italy,  and  from  northern  Europe,  particularly  of  Polish  Jews,  the  people 
from  both  sections,  however,  probably  subject  to  malaria  in  their  home  countries. 
At  this  period,  too,  virulent  malaria  was  frequently  introduced  at  Sparrows 
Point  by  ore  steamers  from  Cuba.  The  city  was  extending  not  only  to  the  north, 
but  to  the  northeast  and  northwest  to  higher  ground.  People  also  settled  in 
the  northeast  along  the  uncovered  portion  of  Harford  Run  and  at  the  extreme 
south  at  Locust  Point  about  docks.  Facilities  for  reaching  the  lower  tide¬ 
water  counties  of  Maryland  and  Virginia  for  vacations  and  excursions  were 
greatly  increased  on  account  of  the  development  of  steamboat  lines.  On  the 
other  hand,  the  clipper  ship  had  well  nigh  disappeared,  and  the  southern  and 
tropical  shipping  trade  was  greatly  curtailed.  Thanks  to  the  improvement  in 
paving,  grading,  and  filling,  the  development  of  more  and  better  storm-water 
sewers,  the  improvement  or  abandonment  of  cow  stables,  the  improvement  in 
garbage  collection  and  nuisance  control,  considerable  changes  for  the  better 
took  place  in  those  general  conditions  which  favor  the  breeding,  protection,  and 
distribution  of  mosquitoes.  Overflowing  cesspools,  somewhat  better  controlled 
than  formerly,  were  not  gotten  rid  of  until  after  malaria  ceased  to  be  a  cause 
of  death  in  Baltimore.  The  recent  anti-mosquito  campaign  of  the  health  de¬ 
partment  came  after  this  date. 

Though  the  physicians  of  Baltimore  in  general,  and  the  leading  physicians 
in  particular,  were  well  grounded  in  the  various  aspects  of  malaria,  and  Coun¬ 
cilman  and  Abbott  (52)  had  confirmed  Lavaran’s  studies  on  the  malaria  para¬ 
site  at  Bayview  Hospital  as  early  as  1885  and  had  taught  the  resident  physi¬ 
cians  of  that  institution  the  methods  of  blood  examination  as  related  to  the 
diagnosis  and  treatment  of  this  disease,  it  was  not  until  the  opening  of  the 
medical  dispensary  and  wards  of  the  Johns  Hopkins  Hospital  under  Osier,  in 
1889,  that  critical  routine  studies  of  the  different  forms  of  the  malarial  para¬ 
sites  in  relation  to  the  various  types  of  malarial  fever  were  regularly  practiced 
in  this  city,  and  a  certain  looseness  in  diagnosis,  not  only  between  the  various 
forms  of  this  disease,  but  between  them  and  wound  infections,  typhoid  fever, 
and  other  diseases,  on  the  part  of  the  general  practitioner  began  to  be  rectified. 
By  1895,  the  activities  of  the  pupils  of  Councilman,  Abbott,  Welch,  and  Osier, 
the  influence  of  these  teachers,  the  entry  upon  the  held  of  consultation  practice 
of  Osier,  Mitchell,  Lockwood,  C.  B.  Gamble  jr.,  Thayer,  Simon,  and  others  so 
reacted  upon  the  other  hospitals  and  upon  general  medical  practice  that  the 


212  PUBLIC  HEALTH  ADMINISTRATION",  ETC.,  IN  BALTIMORE 

diagnosis  of  malaria  became  more  rigid  and  its  treatment  more  exact.  An 
important  role  in  correcting  the  confusion  between  malaria  and  typhoid  fever 
and  tuberculosis  was  played  after  1900  by  the  bacteriological  laboratory  and  by 
the  critical  attitude  of  Dr.  Jones  towards  death  certificates. 

The  decrease  in  malaria  and  its  final  disappearance  as  a  serious  menace  as 
a  cause  of  death  in  Baltimore  are  probably  due  (1)  to  breakdown  in  the  trade 
communications  with  localities  in  which  malaria  in  severe  types  is  endemic; 
(2)  to  the  very  gradual  improvement  in  drainage,  due  to  filling,  grading,  the 
building  of  storm-water  sewers,  and  the  covering  of  the  three  streams  and  the 
straightening  and  narrowing  of  the  bed  of  the  fourth,  Jones  Falls;  (3)  to  the 
gradually  increasing  use  of  cinchona  bark  and  its  preparations,  both  in  treat¬ 
ment  and  in  prevention.  It  has  been  shown  that  malaria  had  almost  entirely 
disappeared  before  the  institution  of  the  organized  anti-mosquito  campaign 
in  1910. 

Of  the  above  measures,  undoubtedly  the  most  important  was  the  freer  use  of 
quinine  during  the  last  50  years,  not  only  in  the  treatment  of  recognized  mala¬ 
ria  and  as  a  preventative,  but  as  a  tonic,  either  alone  or  with  other  drugs  in  the 
treatment  of  all  sorts  of  ailments.  In  the  course  of  time,  a  large  proportion 
of  the  population  was  saturated  with  quinine.  During  much  of  the  time  when 
malaria  was  at  its  worst,  cinchona  bark  and  its  derivatives  were  scarce  and  so 
high  priced  as  to  be  out  of  the  reach  of  a  large  part  of  the  population.  Changes 
in  the  plan  of  treatment  of  severe  malaria,  according  to  which  cinchona  bark 
and  its  preparations  were  given  earlier  and  in  larger  doses,  and  particularly  by 
the  hypodermic  method,  without  waiting  for  results  from  the  bleedings,  emetics, 
purgings,  and  blisterings,  as  was  formerly  the  custom,  must  have  materially 
lowered  the  mortality. 

YELLOW  FEVER. 

In  Chapter  Y,  in  tracing  the  important  part  yellow  fever  played  in  determin¬ 
ing  the  policies  of  public-health  administration  in  Baltimore,  and  particularly 
in  regard  to  quarantine  measures,  some  account  has  been  given  of  the  distribu¬ 
tion  of  the  disease  in  Baltimore  and  of  the  views  held  in  regard  to  its  origin 
and  mode  of  spread,  and  this  need  not  be  repeated  in  detail  here. 

Certain  cardinal  facts  stand  out  clearly,  namely,  that  (1)  yellow  fever  in 
epidemic  form  in  Baltimore  nearly  always  began  at  Fell’s  Point,  the  docking- 
place  of  ocean-going  vessels;  (2)  it  always  remained  limited  to  that  area, 
except  under  the  influence  of  unusually  strong  winds  blowing  over  the  district 
primarily  infected  towards  the  section  secondarily  affected;  (3)  when  cases  of 
yellow  fever  were  removed  from  the  primarily  infected  district  to  high  ground 
(in  the  country  or  at  the  hospital  at  Broadway  and  Monument  Streets), 
secondary  cases  did  not  occur;  and  (4)  when  residents  of  West  Baltimore,  who 
had  contracted  the  disease  while  working  in  or  visiting  the  infected  area  at 
Fell’s  Point,  remained  in  their  homes  and  when  cases  of  yellow  fever  were 
imported  from  Fell’s  Point  into  West  Baltimore  (1797,  1855,  1883,  and  1899), 
there  were  no  recognized  secondary  cases. 

In  the  discussion  of  malaria  it  has  been  shown  that  conditions  favorable  to 
mosquito-breeding,  while  particularly  favorable  at  Fell’s  Point,  must  have 
existed  throughout  at  least  most  of  the  city.  That  the  Anopheles  mosquito 
bred  very  widely  in  Baltimore  is  clear  from  the  known  distribution  of  cases  of 


FEBRILE  DISEASES 


213 


malaria.  From  the  evidence  at  hand  it  would  seem  clearly  established  that  the 
Stegomyia  mosquito  was  at  least  in  most  years  limited  to  FelFs  Point  and  the 
Lazaretto  Point  and  their  immediate  environs.  Perhaps  this  species  of  mos¬ 
quito  rarely,  if  ever,  survived  the  Baltimore  winter,  and,  having  to  be  imported 
each  year  and  arriving  late  in  the  season,  it  did  not  have  opportunity  for  wide 
spreading  from  the  region  of  the  docks  (Lazaretto  and  FelFs  Point)  at  which 
it  landed. 

The  recorded  data  as  to  reported  cases  and  deaths  of  recognized  yellow  fever 
at  the  quarantine  stations  have  been  presented  in  the  chapter  relating  to  quar¬ 
antine.  The  mortality  within  the  city  is  presented  in  table  17  and  graph  2. 

It  is  very  improbable  that,  with  the  large  shipping  trade  between  Baltimore 
and  the  West  Indies  and  Charleston  and  Savannah,  not  to  mention  other  places 
where  yellow  fever  was  indigenous  or  often  epidemic,  the  disease  appeared 
here  for  the  first  time  in  1794.  While  this  year  certainly  marks  the  first  great 
epidemic  of  this  disease  recognized  as  such  in  Baltimore,  it  is  extremely  probable 
that  not  infrequently  before  this  date  from  a  few  to  a  considerable  number  of 
cases  must  have  occurred  and  have  been  mistaken  for  bilious  remittent  malarial 
fever  in  both  mild  and  severe  forms.  Indeed,  Davidge,  one  of  the  first  in  North 
America  to  recognize  that  yellow  fever  is  not  contagious,  held  that  it  was  only 
a  heightened  form  of  malarial  fever,  a  view  shared  by  many  of  his  colleagues ; 
and,  as  a  matter  of  fact,  in  those  of  the  early  epidemics  which  are  recorded  in 
fullest  detail,  the  first  cases  were  invariably  believed  to  be  bilious  remittent 
fever,  and  it  was  only  after  much  investigation,  discussion,  and  consideration 
that  the  existence  of  yellow  fever  was  established  and  officially  acknowledged. 
In  a  community  in  which  some  of  the  leading  physicians  were  honestly  con¬ 
vinced  of  the  fundamental  identity  of  two  affections  with  such  a  large  propor¬ 
tion  of  their  cardinal  symptoms  in  common,  it  was  not  to  be  expected  that  the 
authorities  would  lightly  declare  that  cases  of  the  annual  summer  visitation  of 
continued  fever  belonged  to  the  category  yellow ,  and  thus  advertise  the  pres¬ 
ence  of  a  malady  to  a  prejudiced  world,  which,  in  its  ignorance,  classed  it  as  a 
contagious  pestilence,  thereby,  simply  because  of  the  use  of  a  mere  name  or 
label,  which  in  reality  signified  an  error,  bringing  all  the  disadvantages  and 
losses  entailed  by  a  quarantine  upon  a  seaport  whose  prosperity  depended  upon 
a  free  and  untrammeled  commerce.  This  being  the  attitude  towards  yellow 
fever  and  its  recognition  as  a  separate  disease  after  two  considerable  epidemics 
within  4  years  (1794-1797),  it  is  extremely  unlikely  that,  in  the  loosely  organ¬ 
ized  administration  of  Baltimore  Town  before  the  scare  of  1793,  any  great 
pains  were  exercised  by  either  physicians  or  authorities  to  discriminate  be¬ 
tween  yellow  and  bilious  fever  at  FelFs  Point,  where  illness  and  death  of  con¬ 
tinued  fever  were  common  each  year. 

The  doctrine  of  the  local  origin  of  yellow  fever  and  the  failure  to  recognize 
that  it  was  commonly  imported  on  ships  were  not  peculiar  to  Baltimore  in  the 
latter  part  of  the  eighteenth  and  the  early  years  of  the  nineteenth  centuries; 
the  same  errors  were  made  in  Philadelphia  and  in  Charleston,  South  Caro¬ 
lina.  Notwithstanding  these  opinions,  the  Baltimore  city  council  quarantined 
against  Philadelphia  in  1797  and  again  in  1800,  when  yellow  fever  broke  out 
there  before  its  presence  was  recognized  in  Baltimore. 

Owing  to  lack  of  data  in  regard  to  the  number  of  deaths  annually  ascribed 
to  malarial  fevers  prior  to  1812,  comparative  studies  of  the  death-rates  of 


214  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

malarial  and  yellow  fevers  in  Baltimore  can  not  be  made  for  any  year  prior 
to  1819,  the  first  subsequent  year  with  recorded  deaths  from  yellow  fever. 

The  rather  meager  information  in  regard  to  1794  is  drawn  from  the  accounts 
of  Quinan  and  Cordell,  both  of  whom  wrote  many  years  later.  The  governor’s 
quarantine  officers  and  the  local  board  of  health  were  publicly  criticized  as 
early  as  July  8  for  permitting  yellow  fever  to  gain  entrance,  but  it  was  not 
until  August  13  that  Drs.  Coulter,  Brown,  and  Goodwin  reported  malignant 
bilious  fever  at  Fell’s  Point,  to  which  location  the  disease  was  apparently  con¬ 
fined.  The  board  of  health  reported  the  city  free  of  the  disease  on  October  1 
and  admitted  only  344  deaths  from  all  causes  in  August  and  September. 
Cordell  gives  the  number  of  deaths  due  to  yellow  fever  alone  for  this  year  as 
360.  There  is  no  record  of  the  total  number  of  cases.  If  the  actual  fatalities 
from  yellow  fever  were  360,  and  if  it  is  true  that  the  disease  was  confined  to 
Fell’s  Point,  where  the  total  number  of  inhabitants  could  not  have  far  exceeded 
2,500,  the  attack  and  the  death-rates  were  appalling,  and  the  death-rate  of 
2,400,  calculated  on  the  estimated  population  of  the  whole  town,  high  as  it  is, 
gives  but  a  very  incomplete  idea  of  the  severity  of  the  scourge. 

Concerning  the  yellow  fever  epidemic  of  1797,  there  exist  two  accounts  which 
supplement  each  other,  the  report  of  the  commissioners  of  health  to  the  mayor 
and  city  council  (53),  published  in  the  New  Yorlc  Medical  Repository  for 
November,  1797,  and  the  essay  of  John  B.  Davidge  (33),  published  the  follow¬ 
ing  year. 

The  commissioners  organized  as  a  board  of  health  on  June  5  and  soon  after¬ 
wards  enforced  the  new  quarantine  act  on  shipping  from  the  West  Indies  and 
took  precautions  to  examine  travelers  from  Philadelphia,  when  later  in  the 
season  a  “  malignant  fever  ”  appeared  there. 

During  July  and  August  the  health  of  the  citizens  of  West  Baltimore  was 
unusually  good;  many  nuisances  had  been  removed,  some  low  places  had  been 
filled,  and  the  streets  were  cleaner  than  usual.  In  East  Baltimore  (Fell’s  Point) 
a  “  bilious  complaint  ”  regarded  as  the  common  sickness  of  the  season  com¬ 
menced  early  and  gradually  progressed  to  a  worse  stage.  On  August  26,  in 
response  to  letters  from  the  board,  Drs.  Coulter,  Allender,  and  Joquit,  of 
Fell’s  Point,  while  confessing  to  the  presence  of  a  severe  type  of  continued  fever, 
replied  to  the  effect  that  they  did  not  regard  it  as  departing  from  the  usual 
bilious  remittent  and  intermittent,  and  cited  their  experiences  as  evidence  that 
the  fatality  was  not  high.  According  to  Dr.  Coulter,  on  the  fourth  or  fifth  day, 
if  timely  remedies  had  not  been  applied,  vomiting  of  black  matter  like  coffee- 
grounds  and  sometimes  mixed  with  dark  blood  occurred,  attended  with  profuse 
hemorrhages  from  the  nose,  gums,  and  intestines,  which  generally  carried  the 
victim  off  on  the  sixth  day.  Since  June  he  had  attended  upwards  of  300  such 
cases  and  had  lost  only  8.  At  a  meeting  of  the  physicians  of  the  city  called  on 
August  28,  after  the  reading  of  these  letters  in  reply  to  the  questions  of  the 
president  of  the  board  of  health,  they  all  denied  having  knowledge  of  the  exis¬ 
tence  of  any  contagious  or  yellow  fever,  except  Dr.  Davidge’s  case  of  a  lady 
lately  returned  from  Philadelphia  (previously  narrated  elsewhere)  and  a  sus¬ 
picious  case  attended  by  Dr.  Smith.  The  next  day,  Drs,  Goodwin,  Moores,  and 
Davidge,  who  investigated  the  cases  of  fever  at  Fell’s  Point,  reported  that 
they  “  discovered  nothing  like  a  malignant,  contagious,  or  yellow  fever;  the 


FEBRILE  DISEASES 


215 


patients  whom  we  saw  all  labored  under  the  common  bilious  remittent,  and 
will  generally  recover,  with  common  attention.” 

On  September  3,  five  members  of  the  board,  with  Dr.  Moores  as  medical 
adviser,  investigated  conditions  at  Fell’s  Point,  and  though  they  found  that 
there  had  occurred  a  considerable  extension  of  the  disease,  especially  among 
the  poor,  they  were  not  convinced,  officially  at  least,  that  the  malady  was  yellow 
fever.  The  next  week,  some  days  after  the  gathering  of  a  crowd  of  people  from 
all  parts  of  the  city  to  witness  the  launching  of  a  frigate  at  Fell’s  Point,  there 
was  a  considerable  extension  of  the  disease  in  that  district  and  the  appearance 
of  several  cases  in  West  Baltimore.  On  September  8,  the  first  case  of  yellow 
fever  was  officially  reported  by  Dr.  Moores.  According  to  Davidge,  the  most 
prominent  advocate  of  the  identity  of  bilious  remittent  and  yellow  fever,  “  a 
little  later,  the  disease  raised  from  the  grade  of  bilious  to  yellow  fever  and 
mounted  its  chariot  of  death  and  drove  furiously  through  the  streets  ....  and, 
conveyed  by  the  northeast  wind,  it  scattered  itself  all  along  Federal  Hill  and  the 
west  end  of  the  basin;  whichever  direction  the  miasmata  (arising  from  the 
stagnant  water  along  the  marshes  and  wharves),  controlled  by  the  winds,  took, 
the  disease  tread  closely  upon  its  footsteps.”  It  sped  to  the  end  of  Hanover 
Street  and  its  vicinity  and  in  a  short  time  it  penetrated  “  to  the  vitals  of  the 
city  and  affected  many  who  were  not  near  the  point  or  the  wharves.”  Potter 
gives  the  date  of  the  great  wind  as  September  17  and  its  direction  as  from  the 
southeast,  blowing  the  “  pestilential  effluvia  northwesterly  and  spreading  the 
fever  along  Frederick,  Gay,  South,  and  Calvert  Streets.  Since  it  was  found 
unpracticable  to  transport  the  sick  to  the  quarantine  hospital  at  Hawkins’ 
Point,  a  private  house  near  Fell’s  Point  was  converted  into  a  hospital,  capable 
of  accommodating  but  a  small  proportion  of  the  sick  poor.  At  a  meeting  of  the 
board  of  health  with  the  physicians  on  September  11,  the  latter  advised  against 
the  removal  of  the  inhabitants  of  Fell’s  Point  to  the  country  and  the  cutting  off 
of  communication  between  Fell’s  Point  and  the  rest  of  the  city. 

In  the  report  of  the  board  of  health,  the  actual  number  of  cases  and  deaths 
of  yellow  fever  is  not  given,  but  from  the  following  figures  for  the  total  deaths 
for  almost  equal  periods  before  and  during  the  epidemic  some  estimate  of  its 
ravages  may  be  obtained :  Deaths  from  all  causes,  August  1  to  September  11 
(42  days),  adults  97,  children  74,  total  171;  September  11  to  October  29  (48 
days),  adults  408,  children  137,  total  545.  According  to  Davidge,  the  greatest 
number  of  deaths  in  the  west  end,  or  city  proper,  in  any  one  day  was  8,  while 
the  list  of  deaths  at  the  point  was  for  some  time  considerable.  The  epidemic 
began  to  subside  about  October  1  and  was  nearly  or  quite  extinct  by  Novem¬ 
ber  1.  Of  the  inhabitants  of  Fell’s  Point,  2,679  remained  throughout  the  epi¬ 
demic  and  671  removed. 

From  the  meager  accounts  extant,  it  seems  probable  that  yellow  fever  existed 
at  Fell’s  Point  in  1798  and  certainly  was  present  in  1799,  but  definite  records 
of  the  number  of  cases  and  deaths  are  lacking. 

According  to  the  report  of  the  Medical  Faculty  to  the  mayor  on  the  origin  of 
the  pestilence  in  1800,  the  disease  was  of  domestic  origin  and  not  related  to 
shipping,  having  started  at  Fell’s  Point  in  May,  and  its  principal  source  was 
the  cove  extending  from  the  mouth  of  Jones  Falls  to  the  interior  of  Fell’s  Point. 
Potter  records  that  the  increment  of  cases  could  be  calculated  with  tolerable 


216  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

accuracy  by  observing  the  variations  of  the  winds.  Though  no  record  is  avail¬ 
able  of  the  actual  number  of  cases  and  deaths,  the  epidemic  was  of  considerable 
extent,  for  on  August  28,  the  day  the  disease  was  acknowledged  to  be  yellow 
fever,  the  board  of  health  arranged  to  have  the  cases  reported  to  it  daily  by 
special  messengers.  On  September  2  a  special  encampment  was  established  for 
the  poor  who  wished  to  flee  from  the  disease,  and  on  the  5th,  cases  were  reported 
in  West  Baltimore.  The  epidemic  ceased  October  22.  The  total  deaths  for  the 
year  were  given  as  1,197,  or  a  rate  for  all  causes  of  45. 

Cases  of  yellow  fever  were  recognized  at  FelPs  Point  in  1802,  but  according 
to  the  scanty  accounts  not  in  epidemic  form. 

The  sole  authority  found  for  the  existence  of  yellow  fever  in  1807  is  Potter, 
who  records  it  as  of  special  interest,  to  prove  the  local  origin  of  the  disease, 
since  it  occurred  during  the  period  of  the  embargo,  when  not  a  foreign  ship 
entered  the  port.  He  quoted  Drs.  Allender  and  Clendenin,  who  had  experienced 
the  former  epidemic  at  FelPs  Point  as  attesting  to  the  true  character  of  the  fever. 

Concerning  the  epidemic  of  1819,  the  greatest  since  1794,  and  the  last  one 
of  serious  dimension,  there  is  considerable  literature.  Reese’s  pamphlet  (25)  is 
especially  clear  and  full.  The  first  two  cases  occurred  on  July  21  and  22  in  two 
men  who  frequented  Smith’s  Dock  at  the  point.  At  this  dock  were  two  schoon¬ 
ers,  recently  from  the  West  Indies,  laden  with  coffee  and  hides.  After  the  out¬ 
break  of  these  two  cases,  the  vessels  were  sent  back  to  the  quarantine  grounds, 
but  as  the  health  officer  found  the  crew  healthy  and  the  cargoes  in  good  condi¬ 
tion,  they  were  allowed  to  return  to  dock.  Soon  afterwards,  5  other  cases  of  yel¬ 
low  fever  occurred  in  men  working  on  Smith’s  Dock.  The  outbreak  was  attrib¬ 
uted  to  the  foul  condition  of  Smith’s  Dock  and  the  Frederick  and  Gay  Street 
Docks,  to  the  general  insanitary  condition  of  FelPs  Point,  and  to  two  stagnant 
ponds  between  the  point  and  the  lazaretto.  The  disease  afterwards  broke  out  at 
the  latter  place.  By  August  14,  cases  were  apprehended  at  the  lower  east  end  of 
FelPs  Point,  at  least  a  mile  from  Smith’s  Dock.  By  August  28,  about  50  cases 
had  been  reported,  and  the  deaths  were  said  to  be  about  one-fifth  the  number 
attacked.  Under  the  influence  of  a  strong  southeast  wind,  the  disease  was 
rapidly  spreading  towards  Jones  Falls  and  the  city  to  the  west  of  it,  when, 
after  veering,  the  wind  blew  for  some  days  with  equal  force  from  the  northwest, 
and  the  disease  ceased  to  spread  in  that  direction.  Many  persons,  certainly  over 
half  of  the  population,  fled  from  FelPs  Point,  some  to  the  country  and  others 
to  the  city  proper.  Many  cases  were  sent  to  the  new  Maryland  Hospital  on 
Broadway.  There  were  1,010  cases  reported,  but  Reese  estimated  the  total 
number  of  cases  at  1,200.  The  official  report  placed  the  deaths  at  350. 

Four  deaths  were  credited  to  yellow  fever  in  1821,  but  the  number  of  cases 
was  not  recorded.  In  1853  there  was  a  sudden  outbreak  of  18  cases  of  what  was 
recorded  as  yellow  fever,  all  fatal  and  occurring  within  a  single  block  of 
dwellings  at  FelPs  Point.  The  origin  of  the  disease  was  not  traced.  “  About 
50  cases,”  one-half  of  which  are  said  to  have  proved  fatal,  are  recorded  in  the 
annual  report  of  the  board  of  health  for  1854  as  occurring  at  Fell’s  Point,  in 
the  same  locality  as  in  the  previous  year.  The  disease  was  regarded  as  of  local 
origin.  The  deaths  (13),  from  yellow  fever  occurring  within  the  city  during 
1855  were  all  among  refugees  admitted  from  Norfolk,  Gosport,  or  Portsmouth, 
at  the  entrance  of  the  Bay.  No  secondary  cases  developed  from  these. 


FEBRILE  DISEASES 


217 


Early  in  the  summer  of  1859,  a  vessel  from  the  West  Indies  was  allowed  to 
pass  quarantine  on  account  of  her  bill  of  health,  and  5  laborers,  who  had  been 
engaged  in  unloading  her,  developed  typical  yellow  fever.  Though  they  were 
nursed  in  their  homes,  the  disease  did  not  spread.  A  month  after  the  departure 
of  the  vessel  a  pernicious  fever,  attended  in  some  cases  with  black  vomit, 
appeared  on  FelPs  Point,  and  in  several  cases  it  proved  fatal.  In  1869  there 
were  27  deaths  from  yellow  fever  at  FelPs  Point.  The  71  cases  with  59  deaths 
(44  of  the  latter  within  the  city  and  15  at  the  quarantine  hospital)  in  1876 
were  recorded  as  typho-malarial  fever  by  the  commissioner  of  health.  Dr.  W.  T. 
Councilman,  in  a  personal  communication,  is  the  authority  for  the  statement 
that  Dr.  E.  Lloyd  Howard,  the  quarantine  physician,  who  attended  many  of 
them,  regarded  the  disease  as  certainly  yellow  fever.  According  to  the  report 
of  the  commissioner  of  health,  the  cases  occurred  in  rapid  succession  on  Caroline 
Street  near  Thames  Street,  opposite  to  the  City  Dock.  The  illness  was  very 
acute,  death  often  taking  place  within  24  hours.  Of  the  46  cases  not  removed 
to  the  quarantine  hospital,  only  2  recovered.  The  disease  did  not  spread  beyond 
this  immediate  locality.  The  few  cases  recorded  in  1883  and  1899  developed 
in  sailors  taken  sick  on  ships  at  the  docks  after  passing  quarantine ;  no  secon¬ 
dary  cases  occurred. 

In  the  49  years  between  1850  and  1899,  cases  of  yellow  fever  were  recognized 
at  the  quarantine  station  on  ships  in  23  years  and  the  disease  appeared  in  the 
city  in  at  least  8  of  these  years.  In  only  2  of  these  8  years,  1854  and  1883,  w^as 
the  disease  not  recorded  as  present  on  ships  inspected  at  quarantine.  As  a 
matter  of  fact,  during  the  earlier  years  of  this  period,  as  well  as  during  the  30 
years  between  1821  and  1850,  when  no  cases  and  no  deaths  of  yellow  fever 
were  recorded  in  the  city,  it  is  extremely  probable  that  yellow  fever  often  got 
into  the  city  and  either  was  not  recognized,  or,  if  recognized,  its  presence  was 
not  recorded  by  the  officials.  Considering  the  extensive  commerce  with  yellow- 
fever  infected  places  and  the  looseness  of  the  quarantine  administration  of  a 
city  committed  to  the  doctrine  that  yellow  fever  was  of  local  origin,  it  would  be 
preposterous  to  conclude  that  yellow  fever  completely  failed  to  gain  access  to 
Baltimore  between  1822  and  1853. 

During  this  period,  “  bilious  remittent  ”  fever  was  expected  to  recur  at  FelPs 
Point  widely  spread  and  in  deadly  form  each  summer  and  fall,  and  what  was 
more  likely  and  consistent  than  that  the  cases  of  yellow  fever  occurring  at  the 
same  time  should  be  reckoned  as  belonging  to  the  former  category.  The  remark¬ 
ably  high  death-rates  attributed  to  bilious  fever  during  this  period  would  seem 
to  demand  this  assumption  for  their  explanation. 

The  failure  of  the  disease  to  spread  among  the  inhabitants  of  the  city  in  1855, 
when  there  were  13  deaths  among  refugees  from  Norfolk,  Portsmouth,  and 
Gosport,  is  not  remarkable  in  the  light  of  the  occurrences  of  other  years.  It  is 
likely  that  these  refugees  belonged  exclusively  to  the  type  of  people  who  would 
have  received  shelter  on  the  west  side  of  the  city  on  high  ground,  rather  than 
at  FelPs  Point. 

From  the  resume  given  of  the  history  of  malaria  and  yellow  fever  in  Balti¬ 
more,  it  is  evident  that  in  the  late  years  of  the  eighteenth  and  in  the  earlier 
years  of  the  nineteenth  centuries,  these  two  mosquito-borne  diseases  were  very 
much  confused.  It  is  certain  that  in  the  epidemic  of  1819  many  of  the  earlier 
deaths  at  least  were  attributed  to  bilious  fever  and  that  for  this  year  the  official 


218  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

figures  for  deaths  from  yellow  fever  were  lower  than  actually  experienced.  It 
is  certain  that,  owing  either  to  mistakes  in  diagnosis  or  to  wilful  intent  to  hide 
the  truth,  in  other  years  after  1819  a  considerable  number  of  deaths  from  yellow 
fever  were  ascribed  to  bilious  fever.  Indeed,  in  1853  and  1854,  while  descrip¬ 
tions  of  outbreaks  of  yellow  fever,  with  the  number  of  deaths,  are  given  in  the 
text  of  the  annual  reports,  this  disease  did  not  appear  in  the  official  mortality 
tables.  For  these  two  years  it  has  been  assumed  that  the  deaths  from  yellow 
fever  were  credited  to  bilious  fever,  and  the  figures  in  the  tables  have  been 
corrected  accordingly.  A  similar  correction  has  been  made  for  1876,  when  44 
deaths  from  what  the  quarantine  physician  who  was  well  acquainted  with  the 
disease  called  yellow  fever  were  attributed  to  typho-malaria  by  the  commissioner 
of  health.  While  the  official  figures  for  deaths  credited  to  malaria  and  yellow 
fever  individually  can  not  be  accepted  as  accurate,  the  sum  of  the  deaths  for 
the  two  must  reflect  with  a  fair  degree  of  accuracy  the  total  fatality  from  the 
mosquito-borne  diseases. 

The  averaged  rates  for  5-year  and  10-year  periods  for  total  malaria  and  for 
yellow  fever  taken  together  are  given  in  table  18.  From  1812  to  1825,  these 
affections  were  responsible  for  an  average  annual  death-rate  of  nearly  250.  By 
1826-1830  the  rate  had  fallen  to  104  and  by  1831-1835  to  95.  High  rates  for 
bilious  fever  ended  in  1836  (table  17)  and  it  is  probable  that  the  period  of  fre¬ 
quent  importation  of  severe  tropical  malaria  and  of  yellow  fever  ended  about 
this  time.  It  is  significant  that  bilious  fever  is  described  as  being  most  preva¬ 
lent  and  fatal  at  Fell’s  Point,  the  only  place  where  yellow  fever  flourished.  The 
combined  rate  fell  continuously  until  1846-1850  to  42.  During  the  next  5 
years,  synchronously  with  three  recorded  slight  outbreaks  of  yellow  fever,  the 
rate  rose  to  46.  Falling  to  23  in  1856-1860,  and  remaining  stationary  during 
the  next  5  years  in  connection  with  known  but  small  outbreaks  of  yellow  fever, 
the  rate  rose  between  1865  and  1875  to  52.  The  rise  in  the  rate  in  1881-1885, 
after  a  fall  to  18  in  1875-1880,  was  perhaps  associated  to  some  degree  with 
unrecognized  yellow  fever.  It  is  doubtful  if  yellow  fever  was  responsible  for 
any  considerable  number  of  deaths  after  1876.  With  the  annual  rates  averaged 
for  10-year  periods,  except  for  a  slight  reaction  for  the  decennium  ending  in 
1880,  the  course  of  the  curve  from  1812  to  1920  is  continuously  downwards. 

TYPHUS  FEVER. 

The  local  chroniclers  record  no  serious  epidemic  of  typhus  fever  during  the 
eighteenth  century,  and  its  early  history  in  Baltimore  is  shrouded  in  mystery. 
According  to  Jameson,  it  was  present  in  1799  and  1800.  Typhus  and  typhus 
mitior  are  mentioned  in  the  reports  of  the  censors  of  the  Medical  and  Chirurgi- 
cal  Faculty  as  among  the  diseases  prevalent  in  1809,  1810,  and  1811,  but  not  as 
serious  epidemics.  Typhus  fever  is  so  rarely  alluded  to  before  1852  in  the 
annual  reports  of  the  health  department  that,  but  for  its  appearance  in  the  list 
of  interments  as  a  considerable  cause  of  death,  its  existence  as  a  public-health 
problem  would  not  be  suspected. 

The  sudden  outbreak  of  typhus  fever  in  1814,  with  56  deaths,  as  compared 
with  none  in  1812  and  only  1  in  1813,  may  have  been  due  to  its  spread  from 
local  endemic  foci  of  mild  type  to  the  American  troops  defending  the  city,  to 


FEBRILE  DISEASES 


219 


importation  from  other  American  cities — New  York  or  Philadelphia  for 
instance — or,  on  the  other  hand,  to  contact  on  the  part  of  civilians  or  troops 
with  the  British  forces  operating  in  Maryland.  On  account  of  the  effective 
blockade  of  the  whole  Chesapeake  Bay  by  the  British  fleet,  the  disease  could 
hardly  have  been  imported  directly  from  Europe  to  Baltimore  by  vessels  of 
commerce  in  this  year.  However  this  may  be,  as  may  be  seen  from  table  17, 
graph  2,  there  began  in  1814  an  epidemic  of  great  intensity,  which  extended 
over  a  period  of  15  years,  and  no  year  was  without  fatalities  from  this  cause 
until  1860. 

The  course  of  the  disease  during  the  15  years  between  1813  and  1828,  as 
evidenced  by  the  death-rates,  was  that  of  a  great  epidemic  wave  of  a  virulent 
disease,  in  which  the  death-rate  was  for  13  consecutive  years  over  50  and  which 
was  broken  by  three  very  high  subsidiary  waves.  The  first  of  these  coincides 
with  the  war  with  Great  Britain,  and  the  second  and  third  with  the  period  of 
great  financial  depression  and  want  that  occurred  in  Baltimore  and  elsewhere 
following  the  Napoleonic  Wars,  during  which  typhus  fever  was  particularly 
prevalent  and  virulent  in  Europe.  It  is  likely  that  the  beginning  of  this  great 
wave  was  connected  with  the  introduction  of  the  disease  from  contact  with  the 
British  expeditionary  forces,  and  that  its  continuation  after  peace  in  1815  was 
due  to  constant  reimportations  upon  the  resumption  of  commerce  and  immigra¬ 
tion  with  Europe,  particularly  with  Ireland  and  the  ports  of  Liverpool,  Glas¬ 
gow,  London,  and  Bremen.  During  this  period  the  contribution  of  typhus  fever 
to  the  general  death-rate  was  a  heavy  one. 

The  next  wave,  beginning  in  1829  and  reaching  its  highest  point  in  1832 
with  a  death-rate  of  59,  was  associated  with  the  crowds  of  immigrants,  asserted 
by  the  quarantine  officer  in  1831  to  be  composed  largely  of  the  lame,  halt,  blind, 
and  poverty-stricken,  brought  in  by  vessels  in  ballast  from  Europe,  their  passage 
often  paid  by  the  parishes  from  which  they  came. 

By  1840,  typhus  fever  in  Baltimore  had  become  stabilized  at  a  comparatively 
low  rate  and  remained  so  until  the  definite  epidemic  of  1847-1851,  which  was 
clearly  associated  with  the  great  immigration  in  those  years  from  famine  and 
typhus  stricken  Ireland.  In  1847,  101  cases  of  typhus,  of  whom  17  died,  were 
removed  from  ships  at  quarantine;  and,  as  late  as  1852,  48  cases  were  removed 
from  a  single  ship,  and  of  144  of  her  passengers  held  at  the  lazaretto  for  observa¬ 
tion,  80  developed  the  disease.  From  the  frequently  quoted  work  of  Buckler, 
it  would  appear  that  in  this  epidemic  the  chief  incidence  of  the  disease  was 
among  the  recently  landed  immigrants  and  the  free  blacks.  Among  the  former, 
some  were  sent  directly  from  ships  to  the  almshouse,  and  many  after  they  had 
dwelt  as  servants  in  private  families  for  one  or  two  weeks  after  landing.  In 
May  and  June  of  1849  there  was  an  epidemic  of  typhus  confined  almost  exclu¬ 
sively  to  free  negroes.  “  In  rows  of  houses  occupied  by  Germans,  Irish,  and  free 
blacks,  it  would  invariably  single  out  the  latter,  in  many  instances  seizing  an 
entire  family.”  Of  83  cases,  all  blacks  with  one  exception,  sent  to  the  almshouse 
infirmary,  ranging  in  age  from  5  to  75  years,  39  were  fatal. 

“  The  cases  were  far  more  fatal  in  the  beginning  than  at  the  close  of  the  epidemic; 
of  the  first  18  cases  admitted,  all  died,  and  of  the  last  20,  all  recovered.  The  mystery 
is  why  the  blacks  alone  should  have  suffered.  The  cases  came  from  Strawberry  Alley 
on  the  east,  Run  Alley  on  the  west,  Biddle  Alley  on  the  north,  and  intermediate  points. 
L  Alley,  near  the  center  of  the  city  and  directly  back  of  the  public  stores,  was  entirely 
depopulated.” 

15 


220  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

The  greater  incidence  of  the  disease  among  the  free  than  among  the  slave 
negroes  is  probably  explainable  in  two  ways — the  greater  number  of  the  former 
in  the  population  (over  8  times)  and  their  greater  exposure  and  comparative 
undernourishment.  The  slaves  were  better  housed  on  their  masters*  premises 
and  were  well  fed,  while  the  free  negroes,  relatively  underfed,  lived  largely  in 
alleys  in  closer  contact  with  the  poorer  immigrant  whites.  The  greater  sus¬ 
ceptibility  to  the  disease  of  the  negro  than  the  poor  white  was  probably  due  to 
the  fact  that  he  was  new  to  it  and  that  many  were  heavily  infested  with  lice. 

Buckler  pointed  out  that  the  quarantine  system,  as  conducted,  had  never 
kept  out  the  disease  and  that  the  policy  of  the  city  government  towards  the 
disease  within  the  city  was  hopelessly  ineffectual. 

Between  1856,  when  the  disease  had  again  become  stabilized  at  a  low  rate, 
and  1869,  cases  were  encountered  at  the  quarantine  station  in  only  3  years, 
1857,  1858,  and  1866. 

There  were  flareups  of  the  disease  in  1866-1867,  1870-1871,  and  in  1875, 
and  the  first  two  of  these  coincided  with  European  wars.  In  1870,  282  cases  of 
typhus  were  removed  from  ships  at  quarantine,  and  in  each  of  the  3  succeeding 
years  cases  were  similarly  detected. 

Between  1875  and  1892,  cases  were  apprehended  at  quarantine  in  only  3 
years,  1878,  1887,  and  1892.  Only  2  deaths  were  recorded  in  the  city  between 
1884  and  1918.  The  salient  features  of  the  course  of  typhus  fever  are  well 
brought  out  in  the  annual  mortality  rates  averaged  for  5-  and  10-year  periods 
(table  18,  graphs  3  and  4).  From  the  curves  three  epidemic  waves  stand  out 
distinctly.  Following  the  curve  of  the  rates  averaged  for  5-year  periods,  the 
first  wave,  beginning  with  a  rate  of  77  for  1812—1815,  rose  to  a  peak  with  a 
rate  of  116  in  1821-1825,  and  then  declined  continuously  to  the  low  level  of  12 
in  1841-1845.  The  second  wave  reached  its  sharp  peak  in  1846-1850  with  a 
rate  of  64  and  fell  abruptly  to  its  low  ebb  in  1861-1865.  The  third  wave,  with 
its  flattened  peak,  marked  by  rates  of  5  in  1866-1870  and  of  4  in  1871-1875, 
had  subsided  by  1876-1880.  From  1880  there  was  no  significant  number  of 
deaths. 

Typhus  fever  may  be  said  to  have  run  its  course  in  Baltimore,  certainly 
between  1813  and  1895,  without  any  interference  worthy  of  the  name  by  the 
health  department,  either  by  keeping  the  diseases  from  gaining  entrance  through 
the  port  or  by  restrictive  measures  applied  within  the  city.  No  serious  efforts 
were  made  even  to  secure  the  reporting  of  cases,  and  when  cases  came  to  the 
knowledge  of  the  health  department,  no  adequate  measures  were  taken  to 
prevent  the  spread  of  the  disease.  Hospitalization  was  attempted  in  the  cases 
of  only  some  of  those  who  were  in  such  dire  want  and  affliction  that  they  could 
not  be  taken  care  of  in  their  dwellings,  and  these  were  placed  in  the  public  wards 
of  general  hospitals  without  any  precautions.  The  gradual  disappearance  of 
the  disease  was  due  entirely  to  causes  unconnected  with  local  public-health 
administration. 

No  distinction  was  made  between  typhus  or  typhus  gravior  and  typhus  mitior, 
and  typhoid  fever  did  not  enter  into  the  local  statistical  nosology  until  1851 ; 
therefore  the  question  as  to  the  confusion  of  typhus  and  typhoid  fevers  in  the 
tables  of  causes  of  death  naturally  arises.  This  question  will  be  considered  in 
detail  under  the  discussion  of  the  latter  disease;  suffice  it  here  to  state  that 
there  must  have  been  some  confusion  on  this  point,  certainly  in  the  earlier 


FEBRILE  DISEASES 


221 


years,  that  the  rates  for  typhus  fever  as  given  are  on  this  account  too  high, 
but  that,  on  the  whole,  it  is  probable  that  the  errors  connected  with  typhoid 
fever  affected  the  rates  for  continued  malarial  fever  to  a  much  greater  degree 
than  those  for  typhus  fever.  If  typhoid  fever  was  very  prevalent  and  deaths 
from  it  were  classified  under  typhus  fever  to  any  great  extent,  the  death-rates 
for  the  latter  could  hardly  have  been  so  low  as  they  were  between  1833  and  1845, 
before  typhoid  fever  was  recognized  in  the  statistical  nosology,  or  between  1851 
and  1869,  after  this  event. 

SUMMARY. 

The  course  of  mortality  for  this  group  of  diseases  as  a  whole  is  best  studied 
by  comparing  the  rates  as  averaged  for  5-year  periods  (table  18,  graph  3). 
From  an  average  rate  of  288  for  the  period  ending  in  1815,  the  rates  ascended 
to  376  in  1816-1820  and  381  in  1821-1825.  For  the  10  years  between  1816- 
1825  the  annual  death  toll  from  these  diseases  was  then  not  far  short  of  400, 
and  during  this  time  each  member  of  the  group  reached  the  highest  level 
attained  during  the  period  under  review.  In  the  5  years  ending  in  1830,  the 
picture  completely  changed,  and,  due  to  decreases  in  the  rates  for  each  separate 
disease,  the  total  rate  sank  to  145.  With  the  continued  absence  of  yellow  fever, 
at  least  as  a  recorded  cause  of  death,  and  striking  declines  in  the  rates  for  both 
malaria  and  typhus  fever,  the  total  rate  continued  to  fall  and  by  1841-1845  it 
had  reached  the  comparatively  low  level  of  59.  Owing  to  a  recrudescence  of 
typhus  fever  and  in  the  face  of  an  actual  fall  in  the  rate  for  malaria,  the  total 
rate  rose  to  106  for  the  5  years  ending  in  1850.  During  the  next  5  years,  in 
spite  of  a  return  of  yellow  fever,  the  total  rate  fell  by  50  per  cent.  Between 
1855  and  1865  the  average  rate  was  about  25.  Associated  with  a  rise  in  the 
rates  of  all  three  members  of  the  group,  the  total  rate  ascended  to  41  for  the 
succeeding  5  years,  and  for  the  5  years  ending  in  1875  it  averaged  56.  In  spite 
of  a  slight  turn  of  yellow  fever,  the  total  rate  for  1876-1880  averaged  only  20. 
Due  to  a  rise  in  the  rate  for  malaria,  the  total  rate  rose  to  26  during  the 
following  five  years.  After  1885  the  rate,  with  malaria  now  its  sole  contributor, 
fell  gradually  to  a  negligible  value  in  1920.  Typhus  fever,  responsible  for  a 
large  toll  of  deaths  during  the  early  part  of  the  century,  ran  its  course  in 
epidemic  waves.  The  first  was  the  longest  and  most  severe.  The  last  two  were 
comparatively  mild,  and  each  was  less  severe  than  its  predecessor.  In  each 
epidemic  the  disease  pursued  its  way  uninterfered  with  by  restrictive  measures. 
Cases  were  not  reported  routinely,  isolation  and  disinfection  were  not  practiced, 
and  hospitalization  was  confined  to  the  homeless  and  the  very  poor,  who  were 
placed  indiscriminately  in  the  general  wards.  It  may  be  said,  then,  that  the 
course  of  typhus  fever  in  Baltimore,  until  very  recent  years,  represented  the 
untrammeled  reaction  of  the  disease  upon  the  population.  Though  recurring 
with  a  few  scattered  cases  repeatedly  from  time  to  time  since  the  last  epidemic, 
the  disease,  in  recognized  form,  has  never  gained  a  foothold,  nevertheless,  as  has 
been  shown  by  the  inspection  of  school  children  as  late  as  1915,  a  considerable 
proportion  of  the  population  in  various  sections  of  the  city  was  infested  with 
head  lice. 

In  previous  chapters  it  has  been  made  clear  enough  that  active  administra¬ 
tive  measures  were  directed  against  nuisances  of  the  type  which  favored  the 
recurrence  and  spread  of  malarial  and  yellow  fevers.  The  correctness  of  their 


222  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

view  that  these  diseases  were  not  contagious  in  the  usual  sense  and  their  erron¬ 
eous  belief  that  yellow  fever  was  of  local  origin,  and  that  both  arose  from 
miasmata  generated  in  stagnant  water,  combined  to  lead  the  authorities  on  the 
right  track  in  their  efforts  to  combat  them  by  sanitary  measures.  They  pur¬ 
sued  their  policy  of  securing  dry  cellars,  of  filling  and  draining  low  places,  of 
putting  in  drains,  and  of  straightening  and  covering  streams  as  best  they 
might,  just  as  determinately  and  as  rapidly,  under  the  influence  of  the  old 
miasma  theory,  as  they  would  have  on  the  basis  of  correct  information.  So  far 
as  the  city  was  concerned,  the  difficulty  lay  in  the  fact  that  the  problems 
presented  by  rapidly  expanding  ocean  commerce  with  infected  localities, 
exuberant  population  growth,  and  the  topographical  conditions  were  too  great 
to  be  rapidly  overcome  with  the  means  at  hand.  Lack  of  knowledge  concerning 
the  relation  of  mosquitoes  to  the  propagation  of  these  diseases  was,  of  course, 
a  serious  handicap  that  militated  against  their  efforts  in  many  respects.  The 
closed  or  almost  closed  docks  at  Fell’s  Point  and  the  extensive  marshes  on 
each  side  and  the  pools  of  stagnant  water  on  the  point  itself  furnished  ample 
breeding-places  for  myriads  of  mosquitoes.  Lazaretto  Point,  just  southeast  of 
Fell’s  Point,  where  until  1836  ships  and  cargoes  were  inspected,  aired,  and 
cleansed  and  passengers  and  crews  were  detained,  was  nearly  surrounded  by 
marshes  and  ponds.  Thus  conditions  were  ideal  for  the  perennial  propagation 
of  malaria  in  both  its  milder  indigenous  and  its  severer  imported  forms  and  of 
yellow  fever  when  imported  from  the  tropics  and  from  the  southern  parts  of 
the  United  States.  It  is  probable  that  the  great  drop  in  mortality  from  the 
mosquito-borne  diseases  between  1825  and  1830  was  due  in  large  measure  to 
sanitary  improvements  at  Fell’s  Point  and  about  Lazaretto  Point,  and  that 
the  further  fall  between  1835  and  1845  was  to  a  considerable  degree  the  result 
of  the  destruction  by  fire  in  1836,  of  the  Government  lazaretto  with  the  conse¬ 
quent  abandonment  of  this  place  as  an  inspection-point  for  ocean  shipping. 
With  the  permanent  establishment  of  quarantine  inspection  and  detention  at 
Fairfield  Point  and  later  at  Leading  Point,  as  isolated,  though  mosquito- 
infested  localities  situated  further  from  the  city,  the  chances  of  importing 
pernicious  malaria  and  yellow  fever  at  the  Fell’s  Point  and  other  city  docks 
must  have  been  materially  diminished,  though,  as  the  records  show,  by  no 
means  closed. 

That  part  of  the  city  called  Old  Town,  along  the  east  side  of  Jones  Falls, 
and  the  territory  of  the  city  proper,  situated  along  the  west  side  of  Jones 
Falls  and  the  basin,  were  in  the  early  days  second  only  to  Fell’s  Point  as  centers 
of  malaria.  By  the  end  of  the  first  quarter  of  the  nineteenth  century  consider¬ 
able  improvements  had  been  accomplished  in  these  localities  also  as  the  result 
of  straightening  the  course  of  the  falls,  filling  in  the  marshes  and  other  low 
grounds,  and  grading  and  paving  streets  and  laying  gutters.  Activities  of  this 
character,  together  with  improvements  in  the  banks  and  channels  of  the  lower 
reaches  of  Harford,  Schroeder’s  and  Rutter’s  Runs  and  of  Jones  Falls  were 
prosecuted  with  vigor  during  the  next  25  years.  While  these  measures  were 
never  pushed  to  a.  state  of  completeness  that  entirely  removed  the  conditions 
essential  to  mosquito-breeding  in  the  growing  city,  they  were  probably  in 
large  part  responsible  for  the  fall  in  mortality  from  the  mosquito-borne  dis¬ 
eases  between  1835  and  1860.  The  slight  reaction  in  the  rate  between  1850 


FEBRILE  DISEASES 


223 


and  1855  was  associated  with  the  repeated  importation  of  yellow  fever.  The 
stationary  state  of  the  rate  during  the  Civil  War  period,  when  commerce  with 
the  West  Indies,  Central  and  South  America,  and  the  Confederate  States  was 
cut  off,  suggests  that  the  interference  with  the  importation  of  malaria  from 
these  sources  was  more  than  offset  by  spread  to  the  general  population  of 
malaria  imported  by  Federal  soldiers  invalided  from  the  armies  fighting  in 
the  Southern  States. 

The  decided  increase  in  mortality  from  malarial  fever  during  the  10  years 
subsequent  to  the  Civil  War  was  probably  a  direct  reflection  of  the  resumption 
of  communications  with  malarious  countries  and  the  returning  soldiers,  com¬ 
bined  with  relaxation  in  the  progress  of  sanitary  measures  connected  with 
drainage  and  the  extensive  ditching  operations  involved  in  the  extension  of 
water-mains  at  this  time.  That  malarial  fever  of  severe  grade  was  common  at 
this  time  in  the  newly  built-up  territory  bordering  the  stagnant  Harford  Eun 
is  a  matter  of  record.  There  is  convincing  evidence  that  the  rise  in  the  rates 
for  malaria  between  1885  and  1890  was  associated  with  infection  of  workers  at 
the  steel  works  at  Sparrows  Point,  where  the  disease  in  severe  form  was  con¬ 
stantly  imported  on  ore-carrying  vessels  from  Cuban  ports.  Between  1875 
and  1890  all  the  large  sewer  streams  except  Jones  Falls  and  the  numerous 
uncovered  sewers  were  covered  over,  and  an  increasingly  large  proportion  of 
the  inhabitants  dwelt  upon  high  ground.  Between  1890  and  1920  the  whole 
physical  surface  of  most  of  the  city  was  gradually  changed  by  sanitary  improve¬ 
ments  which  decreased  the  amount  of  standing  water.  However,  in  ravines, 
in  cans  and  other  receptacles  on  ash  dumps,  and  on  the  irregular  surfaces  of 
ill-paved  alleys,  as  late  as  1920,  there  still  remained  opportunities  for  mosquito¬ 
breeding.  The  ditching  involved  in  the  construction  of  the  new  sewerage  system 
between  1906  and  1915  gave  ample  opportunity  for  mosquito-breeding.  Never¬ 
theless,  during  this  whole  period  since  1890  the  death-rates  from  malaria  con¬ 
tinued  to  fall  and  before  the  special  campaign  to  exterminate  the  mosquito  was 
instituted  in  1910  they  had  reached  negligible  proportions. 

These  efforts  continuously,  though  often  but  slowly  and  inffectually,  put 
forth  by  the  city  authorities  to  prevent  and  abate  nuisances  of  the  type  that 
favor  the  spread  of  the  mosquito-borne  diseases  within  the  city  were  not  the 
sole  agencies  at  work.  It  has  been  pointed  out  that  the  opportunities  for  the 
direct  importation  into  the  city  of  malaria  and  yellow-fever  cases  and  of  mos¬ 
quitoes  infected  with  their  causal  agents  were  materially  lessened  by  the 
removal  of  the  quarantine  station  to  more  distant  points  after  1836,  though 
until  very  recent  years  the  quarantine  never  offered  a  complete  barrier.  Though 
the  decrease  in  the  rate  for  yellow  fever  since  1876  must  be  credited  in  great 
degree  to  the  sanitary  improvements  and  to  greater  efficacy  of  quarantine 
measures,  in  large  degree  it  must  have  been  due  to  diminished  prevalence  of 
the  disease  at  ports  of  trade  and  to  the  falling-off  of  shipping.  The  same  con¬ 
siderations  must  apply  also  in  large  part  to  malaria.  Especially  important  in 
connection  with  the  fall  in  the  rates  from  the  latter  disease  has  been  its 
decrease  in  prevalence  and  severity  in  tidewater  Maryland  and  Virginia,  where 
it  was  in  former  years  so  frequently  contracted  by  visitors  from  the  city  and 
whence  it  was  constantly  imported  by  visitors  from  the  rural  districts.  All 


224  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

the  considerable  evidence  at  hand  indicates  that,  significant  as  were  the  bene¬ 
ficial  results  of  administrative  efforts  of  various  kinds,  the  chief  cause  of  the 
decline  in  the  mortality  from  malarial  fever  was  the  saturation  of  the  popula¬ 
tion  with  cinchona  bark  and  its  derivatives. 

ACUTE  INFLAMMATORY  AFFECTIONS  OF  THE 
INTESTINAL  TRACT  CHARACTERIZED  BY 
FREQUENT  LOOSE  STOOLS  OF 
ABNORMAL  COMPOSITION. 

The  term  “  inflammation  ”  is  here  used  in  a  very  wide  sense  to  embrace 
processes  characterized  by  exudates  composed  largely  of  serum  or  plasma  and 
poor  in  corpuscular  elements,  and  associated  with  little  or  even  no  apparent 
loss  of  intestinal  mucosa,  as  well  as  processes  ranging  from  sero-  and  muco¬ 
purulent  exudations  and  desquamative  lesions  to  the  more  severe  inflammatory 
lesions  with  abundant  cellular  exudations,  hemorrhages,  fibrous  false  mem¬ 
branes,  and  proliferation  and  necrosis  of  tissue. 

The  affections  now  to  be  considered  have  long  been  recognized  in  both 
medical  and  statistical  nosology  as  having  one  conspicuous  symptom  in  com¬ 
mon — evacuations  from  the  intestinal  tract  abnormal  in  frequency,  amount, 
and  composition.  The  same  affection  has  gone  under  various  names  at  different 
periods,  as  cholera  morbus,  cramp  colic,  and  diarrhoea,  for  instance;  and  a 
single  term,  as  dysentery,  has  included  several  affections  varying  both  in  ana¬ 
tomical  lesions  and  in  etiology.  Affections  apparently  closely  akin  in  causation 
and  in  other  relationships  as  well  have  been  classified  separately  according  to 
the  age  of  the  victims,  as  cholera  infantum  for  diarrhoea  in  infants  and  diar¬ 
rhoea  or  one  of  its  synonyms  for  similar  disease  in  those  over  2  years  of  age. 
Two  members  of  this  statistical  group,  typhoid  fever  and  Asiatic  cholera,  stand 
out  clearly  both  anatomically  and  causally  as  definite  specific  diseases ;  but  even 
these  have  been  subject  to  much  confusion  with  other  numbers  of  the  group. 
On  the  contrary,  dysentery,  distinguished  in  its  common  clinical  form  by 
characteristic  pain  in  the  lower  bowel  and  by  the  frequent  passage  of  stools 
containing  mucus,  pus,  and  recognizable  blood,  is  not  a  single  anatomical  and 
etiological  entity.  The  amoebic  or  so-called  tropical  dysentery  due  to  Amoeba 
histolytica  and  met  with  at  one  period  in  Baltimore,  has  peculiar  necrotic 
lesions  resulting  in  typical  ulcers  in  the  rectum  and  colon;  but  it  is  by  no 
means  always  acute  and  is  not  invariably  accompanied  with  the  characteristic 
rectal  tenesmus  and  the  purulent  and  bloody  stools  of  the  typical  clinical 
dysentery.  In  fact,  this  form  of  dysentery  often  takes  a  chronic  course,  with 
alternate  constipation  and  diarrhoea,  and  with  stools  resembling  more  closely 
those  of  an  ordinary  diarrhoea  than  those  of  typical  dysentery.  The  type  of 
clinical  dysentery  more  common  in  temperate  climates,  and  recognized  since 
1897  as  caused  by  the  bacillus  of  Shiga  and  its  several  varieties,  and  now 
known  as  bacillary  dysentery,  has  no  characteristic  anatomical  lesion  of  the 
intestine.  The  lesions  vary  in  individual  cases  from  simple  congestion  of  the 
intestinal  mucosa  and  its  lymph  follicles  to  destruction,  with  ulceration  of 
both,  with  or  without  the  deposit  of  fibrinous  false-membranes.  As  will  be 
pointed  out  in  greater  detail  later,  a  not  inconsiderable  proportion  of  the 
deaths  of  infants  classified  under  cholera  infantum  or  summer  complaint  in 


FEBRILE  DISEASES 


225 


Baltimore  in  recent  years  have  been  due  to  infection  with  B.  dysenteries,  with 
consequent  confusion  of  statistical  data.  A  type  of  dysentery  well  known  to 
pathological  anatomists  as  croupous  or  false-membranous  dysentery  and  occur¬ 
ring  often,  but  by  no  means  always,  a‘s  a  complication  of  other  diseases,  is  prob¬ 
ably  not  always  of  specific  etiology,  but  caused  by  a  variety  of  bacteria,  notably 
streptococcus.  Similar  lesions  of  the  rectum  and  colon  occur  in  mercurial 
poisoning. 

Under  this  section  may  be  traced  a  fourth  statistical  rubric,  which  for  lack  of 
a  better  term  will  be  called  diarrhoea.  Here  are  placed  deaths  classified  under 
cholera  morbus,  cramp  colic,  diarrhoea,  inflammation  of  the  bowels,  cholera 
infantum,  and  teething.  According  to  the  best  available  evidence,  drawn  from 
the  traditions  of  local  medical  and  statistical  nosology,  the  last  two  embrace 
the  deaths  now  classified  under  104  of  the  present  international  classification 
of  causes  of  death — diarrhoea  in  persons  under  2  years  of  age.  For  con¬ 
venience  this  last  group  will  be  given  the  title  in  common  usage  in  Baltimore, 
cholera  infantum.  The  other  four  headings,  at  different  periods  in  the  history 
of  the  health  department  varying  in  relative  importance  in  the  statistical 
nosology,  represent  the  present  rubric  105,  or  diarrhoea  in  persons  over  2 
years  of  age.  As  cholera  morbus  until  1821  carried  most  of  the  deaths  for  both 
of  these  rubrics,  the  latter  can  not  be  separated  with  any  degree  of  accuracy 
before  this  date.  As  a  matter  of  fact,  there  is  serious  reason  for  doubting  that 
classification  between  these  two  divisions  of  the  diarrhceal  affections  ever 
approached  accuracy. 

In  this  heterogenous  group  of  affections  called  diarrhoea,  the  structural 
lesions  of  the  intestines  present,  in  general,  no  characteristic  features,  and  are 
often  insignificantly  slight  in  proportion  to  the  severity  of  the  clinical  symp¬ 
toms.  Hypersection  of  mucus,  exudation  of  plasma  in  large  amounts  from  the 
vessels,  changes  in  the  bacterial  flora  of  the  intestines,  with  excessive  fermenta¬ 
tion  and  putrefaction  and  consequent  changes  in  the  character,  consistency, 
and  frequency  of  the  stools,  and  general  prostration,  often  with  rapid  loss  in 
weight,  are  the  prominent  characteristics.  In  severe  cases  the  picture  is 
strikingly  similar  to  that  of  cholera,  with  which  considerable  confusion  has 
existed  at  times. 

These  diseases  have  in  common  a  second  important  characteristic,  viz,  their 
causes  appear  to  be  spread,  chiefly  at  least,  in  the  same  way  by  means  of  foods 
acting  as  vehicles  of  transmission.  They  constitute,  therefore,  the  second  divi¬ 
sion  of  the  nuisance  diseases.  In  certain  foods  recognized  as  particularly  good 
vehicles,  water,  milk,  etc.,  the  causes  of  some  of  these  diseases  frequently  find 
opportunities  favorable  not  only  for  prolonging  existence,  but  for  multiplying 
rapidly.  As  the  causal  agents  are  given  off  from  the  body  with  the  excreta,,  it 
is  not  surprising  that  water,  the  food  most  readily  polluted  with  such  materials 
and  the  one  universal  food  at  all  ages,  should  prove  to  be  their  most  common 
means  of  communication  from  person  to  person ;  and  hence  arises  the  fact  that 
in  this  group  are  found  the  best  known  examples  of  water-borne  diseases. 
Through  foods  infected  directly  or  indirectly  from  previous  cases  seem  to  he 
by  far  the  most  important  vehicles  of  infection,  an  ever-increasing  body  of 
evidence  supports  the  opinion  that,  in  many  instances  at  least,  and  for 
obvious  reasons,  the  infecting  agents  are  conveyed  from  person  to  person  by 
direct  contact.  Ample  evidence  in  favor  of  possibilities  of  this  mode  of  trans- 


226  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


mission  is  apparent  when  it  is  recalled  that,  in  the  natural  course  of  events, 
micro-organisms  present  in  any  considerable  number  in  the  excreta  must  gain 
access  by  means  of  the  garments  to  various  parts  of  the  body  and  finally  to 
the  hands,  at  times  at  least,  of  the  most  fastidiously  cleanly.  However,  in  this 
case,  it  is  probable  that  in  most  instances  the  few  organisms  it  is  thus  possible 
to  convey  from  one  person’s  hands  to  another’s  mouth  are  not  sufficient  for  an 
infective  dose  and  that  successful  conveyance  of  infection  by  hands  usually 
.  requires  the  medium  of  some  food  material  in  which  the  micro-organisms 
may  first  multiply. 

For  obvious  reasons,  the  transmission  of  the  causal  agents  of  these  affections 
from  the  bowel  discharges,  and  even  in  the  case  of  some  of  them  from  the 
urine,  to  human  food  by  insects,  and  notably  by  flies,  is  not  unusual.  Not 
uncommonly  opportunity  arises  for  the  spread  of  some  of  them,  particularly 
amoebic  dysentery,  by  means  of  fresh  vegetables  and  fruits  eaten  raw,  such  as 
cabbage,  lettuce,  cress,  strawberries,  and  the  like,  which  have  been  manured  with 
night-soil.  Possibly  for  all,  and  certainly  for  some  of  them,  the  causal  agents 
persist  in  bowel  and  bladder  discharges  for  varying  periods  after  recovery. 
Some  of  those  who  have  had  typhoid  fever  discharge  B.  typhosus  in  their  urine 
or  feces  many  years  after  recovery.  The  chronic  “  carrier  ”  exerts  an  important 
influence  upon  the  persistence  in  communities  of  some  of  these  diseases,  notably 
typhoid  fever  and  amoebic  dysentery.  Furthermore,  for  some  of  these,  particu¬ 
larly  cholera,  typhoid  and  para-typhoid  fevers,  and  dysentery,  the  “  carrier  ” 
state  may  occasionally  exist  temporarily  in  persons  who  have  never  had  clinical 
manifestations  of  infection.  Too  little  is  known  of  the  behavior  in  the  outside 
world  of  the  causes  of  these  diseases  as  a  class  to  form  an  intelligent  opinion 
concerning  the  sources  and  means  of  infection  unassociated  directly  or  indirectly 
with  human  beings  as  above  outlined.  At  any  rate,  some  of  the  most  prominent, 
as  cholera,  typhoid  fever,  and  dysentery,  have  disappeared  for  considerable 
periods  of  time  when  the  chain  of  direct  and  indirect  infection  between  human 
beings  has  been  broken.  It  would  appear,  therefore,  that  the  human  being  as 
a  host  forms  a  necessary  link. 

Even  a  cursory  study  of  their  history  in  Baltimore  indicates  that  the  pre¬ 
valence  and  lethal  force  of  the  acute  intestinal  affections  have  been  correlated 
with  movements  of  people,  the  age  and  social  composition  of  the  population, 
natural  conditions  of  and  artificial  interferences  with  the  material  environ¬ 
ment,  and  medical  care.  It  is  only  within  comparatively  recent  years  that 
individual  or  personal  efforts  at  their  control  have  been  put  forth  seriously. 
To  trace  separately  and  in  detail  for  each  member  of  the  group  those  particular 
events  in  the  social  and  sanitary  history  of  the  city  that  bear  upon  them  all  in 
common  would  involve  needless  repetition  and  hopeless  confusion.  Clarity 
will  be  gained  by  presenting  the  pertinent  facts  of  the  actual  course  of  each 
affection,  particularly  in  regard  to  its  lethal  force  over  the  whole  period  under 
review,  the  relation  of  the  various  affections  to  each  other  and  to  the  total 
death-rates  for  the  group,  and  the  conditions  which  appear  to  have  influenced 
their  course  favorably  or  unfavorably.  These  acute  intestinal  affections  natu¬ 
rally  fall  under  four  statistical  headings,  as  follows :  Diarrhoeas — cholera 
infantum  (rubric  104)  and  diarrhoea  (rubric  105)  ;  dysentery ;  Asiatic  cholera; 
typhoid  fever. 


FEBRILE  DISEASES 


227 


DIARRHCEAS. 

The  annual  number  of  deaths  ascribed  to  the  heading  cholera  infantum 
(rubric  104)  in  the  local  statistical  nosology  can  not  be  ascertained  before 
1821,  because  they  were  included  with  that  from  cholera  morbus.  Indeed,  it 
would  appear  that  it  was  some  years  later  that  the  separation  became  sharply 
cut.  While  in  a  general  sense  it  is  clear  that,  after  1824  at  least,  cholera  infan¬ 
tum,  in  the  local  statistical  nosology,  has  meant  the  diarrhoeal  affections  of 
infants  below  the  completion  of  the  second  year  of  life,  it  is  by  no  means  certain 
that  it  was  consistently  so  restricted  during  all  this  long  period  of  time.  In 
the  special  tables  for  this  heading  for  1901  to  1904,  inclusive,  the  age  period, 
was  given  as  “  under  5  years,”  and  it  has  been  only  since  1905  that  the  deaths 
have  been  specified  as  “  under  2  years  of  age.”  The  course  of  diarrhoea  (105) 
(table  19,  graph  5)  in  comparison  with  that  of  cholera  infantum  (104)  between 
1880  and  1898,  when,  on  the  whole,  the  former  was  rising  or  was  holding  a 
high  level  and  the  latter  wTas  falling,  suggests  that  some  deaths  of  infants  certi¬ 
fied  as  due  to  diarrhoea  were  classified  under  this  heading  instead  of  under 
cholera  infantum.  The  sharp  rise  in  the  rate  for  cholera  infantum  after  1898, 
associated  with  a  correspondingly  abrupt  drop  for  diarrhoea,  suggests  changes 
in  custom  of  classification  rather  than  in  the  relative  number  of  deaths  from 
these  two  sets  of  causes. 

Between  1812  and  1898  the  records  show  continuously  a  variable  but  consid¬ 
erable  number  of  deaths  attributed  to  teething,  and  during  the  long  period  of 
excessively  high  rates  for  cholera  infantum  between  1845  and  1875  the  number 
of  deaths  classified  under  teething  were  specially  numerous.  On  account  of 
the  testimony  of  physicians  in  practice,  and  especially  of  some  of  those  long 
identified  with  the  health  department,  that  in  the  local  nosology  death  from 
teething  was  synomyous  with  death  from  cholera  infantum  in  the  mind  of  the 
public  and  of  many  physicians,  it  has  seemed  necessary  to  include  deaths  under 
this  heading  in  the  rubric  for  cholera  infantum.  With  the  adoption  of  the 
international  classification  in  1899,  teething  as  well  as  cholera  infantum  gave 
place  to  rubric  104.  There  is  evidence  that  in  some  cholera  years  confusion 
between  cholera  asiatica  and  cholera  infantum  led  to  the  assignment  of  deaths 
from  one  to  the  other  of  these  two  categories.  Finally,  there  is  a  large  possi¬ 
bility  that,  before  1899,  deaths  of  children  under  2  years  of  age  reported  as 
dysentery  may  have  been  classified  by  statistical  clerks  under  that  rubric 
instead  of  under  cholera  infantum,  contrary  to  the  custom  obtaining  since  the 
adoption  of  the  international  classification. 

To  few  diseases  of  common  occurrence  and  high  fatality  has  intensive  study 
over  a  long  period  of  years  yielded  less  in  accurate  knowledge  of  direct  causation 
than  the  gastro-enteritis  or  diarrhoea  of  infants.  In  spite  of  the  large  body  of 
valuable  information  gained  in  regard  to  predisposing  causes  as  ill  care,  unsuit¬ 
able  foods,  heat  and  humidity,  cold,  the  characteristics  of  the  stools,  pathological 
anatomy  and  general  pathology,  preventive  measures  (the  use  of  mother’s  milk, 
properly  prepared  and  selected  cow’s  milk,  and  other  foods),  the  scientific 
general  care  of  infants,  and  even  medical  treatment,  definite  knowledge  of  the 
actual  or  determinative  causes  is  lacking.  Whereas  it  has  long  been  known 
that  at  the  same  or  at  different  dates  there  is  great  difference  in  the  character 
of  the  stools  of  affected  infants,  particularly  in  regard  to  the  presence  or  absence 


228 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


Table  19. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from  diarrhoea, 
dysentery,  cholera,  and  typhoid  fever,  and  the  percentage  of  total  acute  inflammatory  in¬ 
fections  of  the  intestinal  tract  of  total  deaths,  from  1812  to  1920,  inclusive. 

D  =  death.  R  =  rate. 

Diarrhoea. 


Diarrhoea,  under  2  years  of  age. 


Diarrhoea,  2  years  of  age  and  over. 


Year. 

Cholera 

infantum. 

Teething. 

Total. 

Cholera 

morbus. 

Cramp 

colic. 

Diar¬ 

rhoea. 

Inflam¬ 
mation  of 
bowels. 

Total. 

Total. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1812 

•  % 

2 

5 

2 

5 

174 

425 

8 

20 

1 

2 

•  •  • 

183 

447 

185 

452 

1813 

•  • 

6 

14 

6 

14 

179 

418 

11 

26 

•  •  • 

190 

444 

196 

458 

1814 

•  • 

4 

9 

4 

9 

102 

228 

18 

40 

•  •  • 

120 

268 

124 

277 

1815 

•  • 

9 

19 

9 

19 

167 

357 

8 

17 

•  •  • 

175 

374 

184 

394 

1816 

•  • 

3 

6 

3 

6 

132 

270 

16 

33 

•  •  • 

148 

303 

151 

309 

1817 

•  • 

9 

18 

9 

18 

214 

420 

9 

18 

•  •  • 

223 

438 

232 

455 

1818 

•  • 

16 

30 

16 

30 

280 

526 

15 

28 

4 

8 

299 

562 

315 

592 

1819 

•  • 

27 

49 

27 

49 

121 

218 

4 

7 

1 

2 

126 

227 

153 

276 

1820 

•  • 

20 

35 

20 

35 

175 

302 

17 

29 

2 

3 

5 

9 

199 

344 

219 

379 

1821 

•  • 

197 

327 

9 

15 

206 

342 

12 

20 

26 

43 

10 

17 

2 

3 

50 

83 

256 

425 

1822 

•  • 

260 

414 

16 

25 

276 

439 

5 

8 

15 

24 

9 

14 

1 

2 

30 

48 

306 

487 

1823 

•  • 

253 

387 

13 

20 

266 

407 

•  •  • 

•  •  • 

9 

14 

•  •  • 

•  •  • 

6 

9 

15 

23 

281 

430 

1824 

•  • 

90 

132 

4 

6 

94 

138 

5 

7 

11 

16 

1 

1 

8 

12 

25 

37 

119 

175 

1825 

•  • 

93 

131 

14 

20 

107 

151 

7 

10 

17 

24 

37 

52 

•  •  • 

•  •  • 

61 

86 

168 

237 

1826 

•  • 

119 

162 

8 

11 

127 

172 

11 

15 

17 

23 

•  •  • 

•  •  • 

1 

1 

29 

39 

156 

212 

1827 

•  • 

77 

101 

11 

14 

88 

115 

12 

16 

13 

17 

•  •  • 

•  •  • 

6 

8 

31 

40 

119 

155 

1828 

•  • 

110 

138 

16 

20 

126 

158 

9 

11 

7 

9 

1 

1 

10 

13 

27 

34 

153 

192 

1829 

•  • 

140 

170 

1 

1 

141 

171 

7 

8 

15 

18 

•  *  • 

•  •  • 

8 

10 

30 

36 

171 

207 

1830 

•  • 

182 

212 

8 

9 

190 

222 

40 

47 

7 

8 

•  •  • 

•  •  • 

10 

12 

57 

67 

247 

288 

1831 

•  • 

248 

279 

18 

20 

266 

299 

9 

10 

9 

10 

3 

3 

7 

8 

28 

32 

294 

331 

1832 

•  • 

332 

360 

16 

17 

348 

378 

2 

2 

22 

24 

1 

1 

17 

18 

42 

46 

390 

423 

1833 

•  • 

146 

153 

17 

18 

163 

171 

2 

2 

8 

8 

•  •  • 

•  •  • 

22 

23 

32 

34 

195 

204 

1834 

•  • 

201 

203 

23 

23 

224 

226 

35 

35 

23 

23 

1 

1 

14 

14 

73 

74 

297 

300 

1835 

•  • 

89 

87 

23 

22 

112 

109 

5 

5 

10 

10 

•  •  • 

•  •  • 

15 

15 

30 

29 

142 

139 

1836 

•  • 

191 

180 

16 

15 

207 

195 

2 

2 

6 

6 

2 

2 

15 

14 

25 

24 

232 

219 

1837 

•  • 

131 

120 

28 

26 

159 

145 

•  •  • 

•  •  • 

9 

8 

•  •  • 

•  •  • 

10 

9 

19 

17 

178 

162 

1838 

•  • 

199 

176 

21 

19 

220 

194 

2 

2 

4 

4 

•  •  • 

•  •  • 

14 

12 

20 

18 

240 

212 

1839 

•  • 

125 

107 

15 

13 

140 

120 

2 

2 

3 

3 

1 

1 

20 

17 

26 

22 

166 

142 

1840 

•  • 

114 

94 

21 

17 

135 

112 

1 

1 

7 

6 

•  •  • 

•  •  • 

21 

17 

29 

24 

164 

136 

1841 

•  • 

194 

155 

28 

22 

222 

178 

•  •  • 

•  •  • 

4 

3 

•  •  • 

•  •  • 

36 

29 

40 

32 

262 

210 

1842 

•  • 

198 

154 

29 

22 

227 

176 

9 

7 

4 

3 

2 

2 

46 

36 

61 

47 

288 

223 

1843 

•  • 

159 

119 

29 

22 

188 

141 

8 

6 

10 

8 

•  •  • 

•  •  • 

46 

35 

64 

48 

252 

189 

1844 

•  • 

129 

94 

16 

12 

145 

106 

6 

4 

5 

4 

1 

1 

37 

27 

49 

36 

194 

141 

1845 

•  • 

113 

80 

19 

13 

132 

93 

7 

5 

12 

8 

•  •  • 

•  •  • 

34 

24 

53 

37 

185 

131 

1846 

•  • 

139 

95 

42 

29 

181 

124 

4 

3 

8 

5 

•  •  • 

•  •  • 

51 

35 

63 

43 

244 

167 

1847 

•  • 

249 

166 

69 

46 

318 

212 

•  •  • 

•  •  • 

4 

3 

7 

5 

60 

40 

71 

47 

389 

259 

1848 

•  • 

244 

158 

92 

59 

336 

217 

•  •  • 

•  •  • 

6 

4 

15 

10 

67 

43 

88 

57 

424 

274 

1849 

•  • 

290 

182 

102 

64 

392 

246 

32 

20 

9 

6 

69 

43 

46 

29 

156 

98 

548 

344 

1850 

•  • 

347 

212 

99 

60 

446 

272 

27 

16 

9 

5 

40 

24 

54 

33 

130 

79 

576 

351 

1851 

•  • 

290 

172 

93 

55 

383 

227 

6 

4 

11 

7 

15 

9 

66 

39 

98 

58 

481 

285 

1852 

•  • 

339 

195 

120 

69 

459 

265 

10 

6 

13 

8 

49 

28 

78 

45 

150 

86 

609 

351 

1853 

•  • 

256 

144 

94 

53 

350 

196 

11 

6 

28 

16 

34 

19 

80 

45 

153 

86 

503 

282 

1854 

•  • 

395 

216 

114 

62 

509 

278 

129 

70 

111 

61 

39 

21 

55 

30 

334 

182 

843 

460 

1855 

•  • 

418 

222 

169 

90 

587 

312 

22 

12 

22 

12 

30 

16 

88 

47 

162 

86 

749 

398 

1856 

•  • 

568 

294 

206 

107 

774 

400 

14 

7 

11 

6 

6 

3 

88 

46 

119 

62 

893 

462 

1857 

•  • 

410 

207 

206 

104 

616 

310 

12 

6 

24 

12 

14 

7 

74 

37 

124 

62 

740 

373 

1858 

•  • 

361 

177 

210 

103 

571 

280 

10 

5 

32 

16 

7 

3 

87 

43 

136 

67 

707 

347 

1859 

•  • 

386 

185 

163 

78 

549 

263 

17 

8 

21 

10 

16 

8 

68 

33 

122 

58 

671 

321 

1860 

•  • 

328 

153 

204 

95 

532 

248 

13 

6 

25 

12 

6 

3 

84 

39 

128 

60 

660 

308 

1861 

•  • 

325 

148 

225 

102 

550 

250 

8 

4 

48 

22 

8 

4 

63 

29 

127 

58 

677 

308 

1862 

•  • 

266 

118 

157 

70 

423 

188 

13 

6 

57 

25 

15 

7 

55 

24 

140 

62 

563 

250 

1863 

•  • 

287 

124 

157 

68 

444 

192 

13 

6 

77 

33 

13 

6 

57 

25 

160 

69 

604 

261 

1864 

•  • 

309 

130 

150 

63 

459 

194 

10 

4 

87 

37 

9 

4 

68 

29 

174 

73 

633 

267 

1865 

•  • 

285 

117 

112 

46 

397 

164 

30 

12 

79 

33 

21 

9 

61 

25 

191 

79 

588 

242 

1866 

•  • 

340 

137 

151 

61 

491 

198 

40 

16 

109 

44 

21 

8 

41 

17 

211 

85 

702 

283 

FEBRILE  DISEASES 


229 


Table  19. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from  diarrhoea, 

dysentery,  cholera,  and  typhoid  fever,  etc. — Continued. 

D  =  death.  R  =  rate. 

Diarrhoea. 


Diarrhoea,  under  2  years  of  age. 


Diarrhoea,  2  years  of  age  and  over. 


Year. 

Cholera 

infantum. 

Teething. 

Total. 

Cholera 

morbus. 

Cramp 

colic. 

Diar¬ 

rhoea. 

Inflam¬ 
mation  of 
bowels. 

Total. 

Total. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1867 

•  • 

257 

101 

230 

90 

487 

191 

14 

6 

159 

62 

6 

2 

51 

20 

230 

90 

717 

282 

1868 

•  • 

356 

137 

307 

118 

663 

255 

17 

7 

153 

59 

8 

3 

40 

15 

218 

84 

881 

338 

1869 

•  • 

332 

125 

284 

107 

616 

231 

23 

9 

121 

45 

10 

4 

61 

23 

215 

81 

831 

312 

1870 

•  • 

450 

165 

272 

100 

722 

265 

20 

7 

195 

72 

4 

1 

52 

19 

271 

99 

993 

364 

1871 

•  • 

286 

103 

226 

81 

512 

184 

23 

8 

215 

77 

12 

4 

52 

19 

302 

108 

814 

292 

1872 

•  • 

638 

224 

293 

103 

931 

326 

39 

14 

60 

21 

9 

3 

69 

24 

177 

62 

1108 

388 

1873 

•  • 

598 

205 

274 

94 

872 

299 

26 

9 

15 

5 

122 

42 

163 

56 

1035 

355 

1874 

•  • 

766 

257 

284 

95 

1050 

352 

23 

8 

•  •  • 

13 

4 

176 

59 

212 

71 

1262 

423 

1875 

•  • 

643 

211 

119 

39 

762 

250 

22 

7 

•  •  • 

97 

32 

73 

24 

192 

63 

954 

313 

1876 

•  • 

702 

226 

136 

44 

838 

269 

24 

8 

•  •  • 

147 

47 

79 

25 

250 

80 

1088 

350 

1877 

•  • 

615 

193 

143 

45 

758 

238 

16 

5 

•  •  • 

136 

43 

89 

28 

241 

76 

999 

314 

1878 

•  • 

343 

106 

79 

24 

422 

130 

14 

4 

•  •  • 

164 

51 

35 

11 

213 

66 

635 

196 

1879 

•  • 

475 

143 

98 

30 

573 

172 

18 

5 

•  •  • 

160 

48 

40 

12 

218 

66 

791 

239 

1880 

•  • 

503 

149 

104 

31 

607 

179 

25 

7 

•  •  • 

120 

35 

63 

19 

208 

61 

815 

241 

1881 

•  • 

558 

161 

115 

33 

673 

195 

34 

10 

•  •  • 

221 

64 

61 

18 

316 

91 

989 

286 

1882 

•  • 

399 

113 

87 

25 

486 

138 

23 

7 

•  •  • 

166 

47 

62 

18 

251 

71 

737 

209 

1883 

•  • 

473 

131 

91 

25 

564 

157 

18 

5 

•  •  • 

167 

46 

62 

17 

247 

69 

811 

225 

1884 

•  • 

496 

135 

104 

28 

600 

163 

16 

4 

9  0  0 

240 

65 

56 

15 

312 

85 

912 

248 

1885 

•  • 

498 

133 

99 

26 

597 

159 

28 

7 

0  9  0 

186 

50 

56 

15 

270 

72 

867 

232 

1886 

•  • 

485 

127 

98 

26 

583 

153 

13 

3 

0  0  0 

238 

62 

65 

17 

316 

83 

899 

235 

1887 

•  • 

567 

146 

111 

29 

678 

174 

29 

*7 

•  00 

277 

71 

85 

22 

391 

100 

1069 

275 

1888 

•  • 

651 

155 

105 

25 

756 

180 

30 

7 

•  09 

330 

79 

79 

19 

439 

105 

1195 

285 

1889 

•  • 

572 

134 

99 

23 

671 

157 

24 

6 

•  09 

374 

88 

76 

18 

474 

111 

1145 

263 

1890 

•  • 

507 

117 

128 

29 

635 

146 

23 

5 

•  00 

418 

96 

105 

24 

546 

126 

1181 

272 

1891 

•  • 

531 

120 

102 

23 

633 

143 

27 

6 

•  00 

342 

77 

70 

16 

439 

99 

1072 

243 

1892 

•  • 

661 

147 

126 

28 

787 

175 

29 

6 

•  •• 

445 

99 

104 

23 

578 

129 

1365 

304 

1893 

•  • 

444 

97 

112 

25 

556 

122 

35 

8 

•  00 

351 

77 

91 

20 

477 

104 

1033 

226 

1894 

•  • 

440 

95 

77 

17 

517 

111 

18 

4 

•  00 

419 

90 

72 

16 

509 

110 

1026 

221 

1895 

•  • 

510 

108 

95 

20 

605 

129 

17 

4 

•  90 

400 

85 

77 

16 

494 

105 

1099 

233 

1896 

•  • 

412 

86 

68 

14 

480 

100 

22 

5 

•  00 

373 

78 

92 

19 

487 

102 

967 

202 

1897 

•  • 

401 

83 

75 

15 

476 

98 

14 

3 

•  00 

410 

84 

80 

16 

504 

104 

980 

202 

1898 

•  • 

386 

78 

65 

13 

451 

91 

12 

2 

•  00 

490 

99 

18 

4 

520 

105 

971 

197 

1899 

•  • 

703 

141 

•  •  • 

703 

141 

16 

3 

•  00 

165 

38 

•  •  • 

181 

36 

884 

177 

1900 

•  • 

848 

167 

•  •  • 

848 

167 

6 

1 

•  00 

105 

21 

•  •  • 

111 

22 

959 

189 

1901 

•  • 

726 

141 

•  •  • 

726 

141 

7 

1 

•  00 

88 

17 

•  00 

95 

18 

821 

160 

1902 

•  • 

695 

133 

•  •  • 

695 

133 

16 

3 

•  00 

82 

16 

•  00 

98 

19 

793 

152 

1903 

•  • 

550 

104 

•  •  • 

550 

104 

8 

2 

•  •  • 

68 

13 

•  •  • 

76 

14 

626 

119 

1904 

•  • 

671 

126 

•  •  • 

671 

126 

6 

1 

•  •  • 

72 

13 

•  •  • 

78 

15 

749 

140 

1905 

•  • 

751 

139 

•  •  • 

751 

139 

4 

1 

•  •  • 

86 

16 

•  •  • 

90 

17 

841 

156 

1906 

•  • 

623 

114 

•  •  • 

623 

114 

4 

1 

•  •  • 

86 

16 

•  00 

90 

16 

713 

130 

1907 

747 

135 

•  •  • 

747 

135 

11 

2 

•  •  • 

122 

22 

•  00 

133 

24 

880 

159 

1908 

591 

106 

•  •  • 

591 

106 

15 

3 

•  00 

109 

19 

•  00 

124 

22 

715 

128 

1909 

562 

99 

•  •  • 

562 

99 

5 

1 

•  00 

119 

21 

•  •  • 

124 

22 

686 

121 

1910 

•  • 

598 

105 

•  •  • 

598 

105 

6 

1 

•  •  • 

113 

20 

•  •  • 

119 

21 

717 

125 

1911 

568 

98 

•  •  • 

568 

98 

3 

1 

.  .  . 

83 

14 

•  •  • 

86 

15 

654 

113 

1912 

•  • 

501 

86 

•  •  • 

501 

86 

3 

1 

.  .  . 

88 

15 

•  •  • 

91 

16 

592 

101 

1913 

#  # 

558 

95 

•  •  • 

558 

95 

2 

.  .  . 

83 

14 

•  •  • 

85 

14 

643 

109 

1914 

•  * 

564 

95 

•  •  • 

564 

95 

.  .  . 

78 

13 

•  •  • 

78 

13 

642 

108 

1915 

•  • 

480 

80 

•  •  • 

480 

80 

91 

15 

•  90 

91 

15 

571 

95 

1916 

•  • 

581 

96 

•  •  • 

581 

96 

83 

14 

.  .  . 

83 

14 

664 

109 

1917 

• 

•  • 

635 

104 

•  •  • 

635 

104 

.  .  . 

101 

16 

•  •  • 

101 

16 

736 

120 

1918 

•  • 

795 

129  ' 

•  •  • 

795 

129 

143 

23 

•  •  • 

143 

23 

938 

152 

1919 

•  • 

616 

85 

•  •  • 

616 

85 

.  .  . 

134 

19 

•  •  • 

134 

19  | 

750 

104 

1920 

•• 

663 

90  l 

. . . 

663 

90 

.  .  . 

. . . 

105 

14 

.  .  . 

. . . 

105 

14 

768 

105 

230  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


Table  19. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from  diarrhoea, 

dysentery,  cholera,  and  typhoid  fever,  etc. — Continued. 


D  =  death.  R  =  rate. 


Year. 

Dysen¬ 

tery. 

Cholera. 

Typhoid  fever. 

Grand 

total. 

Per 

cent. 

of 

total 

deaths. 

Nervous 

fever. 

Gastric 

fever. 

Typho- 

malarial 

fever. 

Typhoid 

fever. 

Total. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1812 

2 

5 

2 

5 

187 

457 

16 

1813 

•  •  • 

•  •  • 

•  •  • 

•  •  • 

,  *  * 

.  .  . 

... 

•  •  • 

196 

458 

17 

1814 

•  •  • 

6 

13 

•  •  • 

3 

7 

. . . 

3 

7 

133 

297 

12 

1815 

•  •  • 

7 

15 

•  •  • 

1 

2 

.  .  . 

1 

2 

192 

411 

14 

1816 

•  •  • 

12 

25 

•  •  • 

5 

10 

5 

10 

168 

344 

13 

1817 

•  •  • 

10 

20 

•  •  • 

2 

4 

... 

2 

4 

244 

479 

18 

1818 

•  •  • 

31 

58 

•  •  • 

7 

13 

7 

13 

353 

664 

21 

1819 

•  •  • 

26 

47 

•  •  • 

2 

4 

2 

4 

181 

326 

8 

1820 

•  •  • 

64 

111 

•  •  • 

5 

9 

•  •  • 

5 

9 

288 

498 

19 

1821 

•  •  • 

41 

68 

•  •  • 

5 

8 

. . . 

•  •  . 

5 

8 

302 

501 

16 

1822 

•  •  • 

56 

89 

•  •  • 

•  •  • 

•  •  • 

... 

•  •  • 

362 

576 

16 

1823 

•  •  • 

46 

70 

•  •  • 

9 

14 

9 

14 

336 

514 

17 

1824 

•  •  • 

13 

19 

•  •  • 

2 

3 

•  *  * 

2 

3 

134 

197 

10 

1825 

■  •  • 

30 

42 

•  •  • 

198 

280 

14 

1826 

•  •  • 

47 

64 

•  •  • 

203 

276 

11 

1827 

•  •  • 

20 

26 

•  •  • 

139 

181 

10 

1828 

•  •  • 

20 

25 

•  •  • 

173 

218 

11 

1829 

•  •  • 

12 

15 

•  •  • 

183 

222 

11 

1830 

•  •  • 

21 

25 

•  •  • 

268 

313 

14 

1831 

•  •  • 

24 

27 

•  •  • 

318 

358 

15 

1832 

•  •  • 

58 

63 

853 

926 

1301 

1412 

38 

1833 

•  •  • 

32 

34 

•  •  • 

227 

238 

10 

1834 

•  •  • 

39 

39 

71 

72 

407 

412 

16 

1835 

•  •  • 

28 

27 

•  •  • 

170 

166 

9 

1836 

•  •  • 

25 

24 

•  •  • 

257 

243 

9 

1837 

•  •  • 

39 

36 

•  •  • 

3 

3 

3 

3 

220 

201 

9 

1838 

•  •  • 

25 

22 

•  •  • 

5 

4 

5 

4 

270 

238 

11 

1839 

•  •  • 

16 

14 

•  •  • 

8 

7 

8 

7 

190 

162 

8 

1840 

•  •  • 

27 

22 

•  •  • 

10 

8 

10 

8 

201 

166 

10 

1841 

•  •  • 

22 

18 

•  «  • 

7 

6 

7 

6 

291 

233 

13 

1842 

•  •  • 

25 

19 

•  •  • 

12 

9 

*  *  * 

12 

9 

325 

252 

13 

1843 

•  •  • 

22 

17 

•  •  • 

1 

1 

17 

13 

18 

14 

292 

219 

13 

1844 

•  •  • 

13 

9 

•  •  • 

2 

1 

22 

16 

24 

17 

231 

168 

9 

1845 

•  •  • 

13 

9 

1 

1 

2 

1 

36 

25 

.  •  . 

38 

27 

237 

167 

8 

1846 

•  •  • 

7 

5 

25 

17 

*  *  * 

25 

17 

276 

189 

9 

1847 

•  •  • 

42 

28 

29 

19 

... 

29 

19 

460 

306 

13 

1848 

•  •  • 

46 

30 

•  •  • 

4 

3 

20 

13 

24 

16 

494 

319 

13 

1849 

•  •  • 

148 

93 

•  •  • 

4 

3 

21 

13 

25 

16 

721 

453 

17 

1850 

•  •  • 

237 

145 

•  •  • 

3 

2 

30 

18 

33 

20 

846 

516 

20 

1851 

•  •  • 

161 

95 

•  •  • 

19 

11 

71 

42 

90 

53 

732 

434 

18 

1852 

•  •  • 

222 

128 

•  •  • 

14 

8 

78 

45 

92 

53 

923 

532 

19 

1853 

•  •  • 

242 

136 

•  •  • 

18 

10 

101 

57 

119 

67 

864 

485 

18 

1854 

•  •  • 

252 

138 

2 

1 

15 

8 

95 

52 

110 

60 

1207 

659 

23 

1855 

•  •  • 

202 

107 

•  •  • 

14 

7 

94 

50 

108 

57 

1059 

563 

21 

1856 

•  •  • 

213 

110 

•  •  • 

13 

7 

69 

36 

82 

42 

1188 

614 

23 

1857 

•  •  • 

141 

71 

•  •  • 

10 

5 

.  .  . 

84 

42 

94 

47 

975 

491 

19 

1858 

•  •  • 

137 

67 

•  •  • 

7 

3 

100 

49 

107 

53 

951 

467 

18 

1859 

•  •  • 

104 

50 

•  •  • 

9 

4 

92 

44 

101 

48 

876 

419 

19 

1860 

•  •  • 

59 

28 

•  •  • 

8 

4 

101 

47 

109 

51 

828 

386 

17 

1861 

•  •  • 

51 

23 

•  •  • 

9 

4 

167 

76 

176 

80 

904 

411 

19 

1862 

m  m  m 

43 

19 

11 

5 

202 

90 

213 

94 

819 

363 

16 

1863 

•  •  • 

60 

26 

•  •  • 

12 

5 

168 

73 

180 

78 

844 

365 

15 

1864 

•  •  • 

73 

31 

•  •  • 

5 

2 

200 

84 

205 

87 

911 

385 

16 

1865 

•  •  • 

67 

28 

•  •  • 

4 

2 

.  .  . 

171 

70 

175 

72 

830 

342 

18 

1866 

.  .  . 

67 

27 

62 

25 

5 

2 

. . . 

196 

79 

201 

81 

1032 

415 

18 

FEBRILE  DISEASES 


231 


Table  19. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from  diarrhoea, 

dysentery,  cholera,  and  typhoid  fever,  etc. — Continued. 


D  =  death.  It  =  rate. 


Year. 

Dysen¬ 

tery. 

Cholera. 

Typhoid  fever. 

Grand 

total. 

Per 

cent. 

of 

total 

deaths 

Nervous 

fever. 

Gastric 

fever. 

Typho- 

malarial 

fever. 

Typhoid 

fever. 

Total. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1867 

63  ! 

25 

11 

4 

•  •  • 

235 

92 

246 

97 

1026 

403 

19 

1868 

•  •  • 

85 

33 

9 

3 

•  •  • 

167 

64 

176 

68 

1142 

438 

18 

1869 

•  •  • 

83 

31 

. .  t 

14 

5 

•  •  • 

210 

79 

224 

84 

1138 

427 

18 

1870 

65 

24 

25 

9 

•  •  • 

265 

97 

290 

106 

1348 

494 

19 

1871 

•  •  • 

83 

30 

9 

3 

•  •  • 

200 

72 

209 

75 

1106 

397 

15 

1872 

71 

25 

15 

5 

•  •  • 

229 

80 

244 

86 

1423 

499 

16 

1873 

. . . 

76 

26 

15 

5 

•  •  • 

230 

79 

245 

84 

1356 

465 

18 

1874 

•  •  • 

71 

24 

.  .  .  1 

16 

5 

•  •  • 

226 

76 

242 

81 

1575 

528 

21 

1875 

•  •  • 

48 

16 

25 

8 

... 

187 

61 

212 

70 

1214 

398 

17 

1876 

57 

18 

6 

2 

177 

57 

183 

59 

1328 

427 

18 

1877 

49 

15 

4 

1 

... 

•  •  • 

•  •  • 

•  •  • 

•  •  • 

212 

67 

212 

67 

1264 

397 

16 

1878 

41 

13 

3 

1 

... 

177 

55 

180 

55 

856 

264 

13 

1879 

. . . 

60 

18 

2 

1 

•  •  • 

•  •  • 

6 

2 

17 

5 

167 

50 

190 

57 

1043 

314 

14 

1880 

•  •  • 

57 

17 

5 

1 

31 

9 

197 

58 

233 

69 

1105 

326 

14 

1881 

•  •  • 

56 

16 

5 

1 

50 

14 

197 

57 

252 

73 

1297 

375 

15 

1882 

•  •  • 

62 

18 

1 

•  •  • 

44 

12 

165 

47 

210 

60 

1009 

286 

11 

1883 

•  •  • 

52 

14 

3 

1 

48 

13 

126 

35 

177 

49 

1040 

289 

11 

1884 

. . . 

43 

12 

4 

1 

66 

18 

151 

41 

221 

60 

1176 

320 

14 

1885 

•  •  • 

60 

16 

75 

20 

155 

41 

230 

61 

1157 

309 

14 

1886 

•  •  • 

84 

22 

1 

... 

58 

15 

150 

39 

209 

55 

1192 

312 

14 

1887 

•  •  • 

138 

35 

55 

14 

156 

40 

211 

54 

1418 

364 

17 

1888 

•  •  • 

167 

40 

41 

10 

161 

38 

202 

48 

1564 

373 

18 

1889 

•  •  • 

156 

37 

33 

8 

191 

45 

224 

52 

1525 

357 

18 

1890 

•  •  • 

212 

49 

54 

12 

247 

57 

301 

69 

1694 

390 

17 

1891 

•  •  • 

18 

4 

39 

9 

150 

34 

189 

43 

1279 

289 

13 

1892 

•  •  • 

109 

24 

33 

7 

193 

43 

226 

50 

1700 

378 

16 

1893 

•  •  • 

62 

14 

31 

7 

224 

49 

255 

56 

1350 

296 

14 

1894 

•  •  • 

72 

16 

35 

8 

222 

48 

257 

55 

1355 

292 

14 

1895 

. . . 

70 

15 

19 

4 

173 

37 

192 

41 

1361 

289 

13 

1896 

82 

17 

16 

3 

188 

39 

204 

43 

1253 

262 

13 

1897 

57 

12 

1 

•  •  • 

20 

4 

189 

39 

210 

43 

1247 

257 

13 

1898 

. . . 

82 

17 

12 

2 

189 

38 

201 

41 

1254 

254 

12 

1899 

. . . 

57 

11 

153 

31 

153 

31 

1094 

219 

11 

1900 

77 

15 

189 

37 

189 

37 

1225 

242 

11 

1901 

. . . 

49 

10 

141 

27 

141 

27 

1011 

197 

10 

1902 

. . . 

78 

15 

220 

42 

220 

42 

1091 

210 

11 

1903 

40 

8 

189 

36 

189 

36 

855 

162 

8 

1904 

. . . 

54 

10 

199 

37 

199 

37 

1002 

188 

9 

1905 

44 

8 

197 

36 

197 

36 

1082 

200 

10 

1906 

37 

7 

183 

33 

183 

33 

933 

171 

9 

1907 

48 

9 

230 

42 

230 

42 

1158 

209 

10 

1908 

. . . 

35 

6 

180 

32 

180 

32 

930 

166 

9 

1909 

33 

6 

136 

24 

136 

24 

855 

151 

8 

1910 

•  •  • 

31 

5 

235 

41 

235 

41 

983 

172 

9 

1911 

•  •  • 

25 

4 

154 

27 

154 

27 

833 

144 

8 

1912 

•  •  • 

17 

3 

136 

23 

136 

23 

745 

128 

7 

1913 

•  •  • 

21 

4 

135 

23 

135 

23 

799 

135 

8 

1914 

•  •  • 

10 

2 

130 

22 

130 

22 

782 

131 

7 

1915 

12 

2 

128 

21 

128 

21 

711 

118 

7 

1916 

7 

1 

107 

18 

107 

18 

778 

128 

7 

1917 

•  •  • 

5 

1 

92 

15 

92 

15 

833 

136 

7 

1918 

•  •  • 

5 

1 

73 

12 

73 

12 

1016 

164 

6 

1919 

•  •  • 

3 

60 

8 

60 

8 

813 

113 

7 

1920 

•  •  • 

22 

3 

35 

5 

35 

5 

825 

112 

7 

232  PUBLIC  HEALTH  ADMINISTRATION-,  ETC.,  IN  BALTIMORE 

of  blood  and  pus,  it  has  been  commonly  assumed  that  the  affection  is  a  single 
and  distinct  entity,  and  the  work  of  pathological  anatomists  and  of  bacteri¬ 
ologists,  including  that  of  Booker  (54),  in  1895,  who  found  streptococci  in 
the  intestinal  lesions  of  a  group  of  cases,  and  of  Duval  and  Bassett  (55),  in 
1902,  who  cultivated  varieties  of  B.  dysenteric  from  the  stools  of  certain  Balti¬ 
more  cases,  did  not  seriously  upset  this  prevailing  conception. 

The  recent  demonstration  by  Professor  John  Howland  (personal  communi¬ 
cation)  and  his  coworkers  that  B.  dysenteric ,  in  relation  to  infantile  diarrhoeas 
in  Baltimore,  is  confined  strictly  to  cases  with  bloody  stools  and  that  this  form 
of  bowel  affection  occurs  from  time  to  time  in  epidemic  outbreaks  in  widely 
separated  areas  in  Baltimore  and  may  spread  among  children  with  other  affec- 


Graph  5  (from  table  19).  Animal  crude  mortality  rates  from  diarrhoea,  from 

1812  to  1920,  inclusive. 

tions  in  a  well  administered  hospital  when  cases  are  admitted  to  the  wards,  is 
of  far-reaching  importance.  Thus,  for  Baltimore,  it  appears  to  be  conclusively 
established  that  this  rubric,  cholera  infantum,  consists  of  at  least  two  separate 
elements,  the  dysentery  and  the  non-dysentery.  The  dysentery  type  of  infantile 
enteritis  is  often  particularly  fatal,  but  no  data  exist  for  comparing  its  lethal 
powers  with  the  group  or  groups  of  other  types  and  causation.  That  dysentery 
was  an  important  cause  of  death  among  infants  is  shown  by  the  high  death- 
rate  under  1  year  of  age  from  this  disease  in  1850.  William  T.  Howard,  sr.  (86), 
was  struck  with  the  close  relationship  between  cholera  infantum  and  dysentery, 
and  in  his  lectures  written  about  1870  stated  that  when  the  infant  in  a  family 
became  ill  with  cholera  infantum,  older  children  in  the  same  household  were 
often  attacked  by  typical  dysentery. 


FEBRILE  DISEASES 


233 


It  will  be  noted  from  table  19  that  high  death-rates  from  cholera  infantum 
have  often,  but  by  no  means  invariably,  synchronized  in  time  with  high  rates 
for  dysentery,  and  there  would  appear  to  be  a  rough  sort  of  correlation  in  the 
simultaneous  fall  in  these  two  rates  particularly  during  the  last  few  years. 
However,  since  knowledge  concerning  the  proportional  distribution  of  the 
deaths  ascribed  to  dysentery  among  the  several  varieties  of  this  disease  as 
clinically  and  anatomically  defined  is  entirely  lacking,  any  attempt  at  close 
comparison  between  its  course  and  that  of  cholera  infantum  is  manifestly 
unwarranted.  Whether  the  non-dysentery  moiety  of  infantile  enteritis  is  due 
to  the  same  indefinite  congeries  of  causes,  to  which  the  diarrhoeas  of  older 
children  and  adults  is  ascribed,  is,  of  course,  unknown.  It  must  be  clearly 
recognized  that,  as  here  used,  cholera  infantum  is  from  neither  the  etiological 
nor  the  anatomical  standpoints  a  specific  disease  entity,  but  that  it  embraces 
deaths  which  under  a  proper  causal  classification  would  be  ascribed  to  dysentery, 
and  in  other  ways  it  is  not  strictly  comparable  with  diarrhoea  (rubric  105), 
which,  in  theory  at  least,  avowedly  excludes  all  dysenteries. 

Assuming  for  the  purpose  of  the  present  study  that  the  figures  recorded  for 
deaths  from  cholera  infantum  and  teething  are  correct,  and  that  these  headings 
taken  together  represent,  from  1821  to  1898,  the  later  rubric  104  of  the 
international  classification,  the  course  of  its  force  of  mortality  may  be  followed 
for  100  years.  Such  rates  are  far  from  specific  as  regards  age  of  those  exposed 
to  risk  and  much  less  so  than  those  calculated  for  dysentery  and  for  diarrhoea. 
For  according  to  definition,  in  calculating  the  rates  for  the  latter  rubric,  the 
divisor  includes  erroneously  the  relatively  small  age-group  under  the  second 
year  of  age  and  from  the  dividend  the  deaths  from  these  affections  within  this 
age-group  are  excluded,  while  in  the  rates  for  cholera  infantum  the  divisor 
includes  the  comparatively  great  moiety  of  population  above  the  second  year 
used  upon  a  dividend  represented  by  the  number  of  deaths  within  this  very 
restricted  age  group.  On  this  basis,  for  direct  comparison,  the  rates  for  cholera 
infantum  would  have  to  be  multiplied  something  over  20  times.  And  again, 
strict  comparison  of  the  rates  for  this  rubric  for  the  earlier  years  with  those  of 
the  later  years  is  unwarranted  because  of  changes  in  the  age-groupings  of  the 
population.  It  is  evident  that  the  rate  for  cholera  infantum  would  be  materially 
affected  by  changes  in  the  birth-rate,  and  by  the  rise  and  fall  in  the  death  rates 
from  such  affections  as  measles,  scarlet  fever,  whooping-cough,  and  diphtheria. 

Even  while  bearing  constantly  in  mind  these  various  explanations  and 
reservations  made  necessary  by  the  character  of  the  data  available  (from  study 
of  table  19  and  graph  5),  it  is  abundantly  evident  that  the  annual  rates  for 
cholera  infantum,  as  calculated,  are  not  only  very  high  and  show  frequently 
substantial  variations  from  year  to  year,  but  exhibit  several  major  and  minor 
waves  often  extending  over  periods  embracing  a  considerable  number  of  years. 
In  other  words,  the  force  of  mortality,  always  considerable,  has  often  varied 
widely  from  year  to  year  and  from  period  to  period  in  the  population’s  history. 
Beginning  some  time  before  1821  and  ending  in  1823,  there  was  a  wave  of 
appalling  mortality.  The  rate  for  1822  (439  per  100,000  total  population,  but 
something  like  10,000  per  100,000,  or  1  in  every  10  exposed  to  risk,  i.  e.,  under 
the  second  year  of  age)  was  higher  than  any  since  recorded.  A  rate  even  higher 
probably  obtained  in  1818.  The  abrupt  fall  in  1824,  with  the  slight  rise  during 
the  next  2  years,  was  followed  by  the  termination  of  this  wave  in  1827  with 


234  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

a  rate  of  115.  A  second  wave  starting  in  1828  reached  its  peak  in  1832  (the 
year  of  the  great  cholera  epidemic)  with  a  rate  of  378;  after  a  substantial  fall 
the  next  year  and  a  minor  rise  in  1834  (the  second  cholera  year),  it  fell  to  a 
low  point  (109)  in  1835.  This  sharply  cut  wave,  attended  with  correspondingly 
higher  rates  for  diarrhoea,  and  with  a  rate  higher  than  usual  for  dysentery  in 
the  peak  year  (1832),  covered  a  period  of  7  years.  The  next  10  years  was  a 
period  of  relatively  low  rates,  with  considerable  annual  fluctuation,  and  in  1845 
the  remarkably  low  rate  of  93  was  attained.  During  this  10-year  period  the 
rates  for  dysentery  were  low  and  on  the  whole  declining,  and  those  for  diarrhoea, 
which  fell  during  the  first  half,  rose  correspondingly  in  the  second  half. 

The  year  1846  signaled  the  beginning  of  a  third  wave  of  mortality,  which, 
mounting  gradually  and  broken  now  and  again  by  slight  recessions,  reached 
its  peak  in  1856  with  a  rate  of  .400,  and  descending  gradually,  subsided  in  1865 
with  a  rate  of  164.  During  the  first  half  of  this  20-year  wave  the  rates  for  both 
diarrhoea  and  dysentery  were  high,  and  indeed  reached  their  highest  recorded 
level,  the  latter  in  1850  and  the  former  in  1854  (a  cholera  year,  when,  however, 
practically  all  the  deaths  from  cholera  must  have  been  credited  to  diarrhoea 
and  cholera  infantum).  During  the  last  half  of  the  period  the  rates  for 
dysentery  subsided  sharply  and  markedly  and  those  for  diarrhoea  first  fell  and 
later  rose. 

It  will  he  noted  that  cholera  infantum  achieved  its  highest  rate  2  years 
later  than  diarrhoea  and  6  years  later  than  dysentery.  In  a  fourth  great  wave, 
extending  from  1866  to  1878,  the  rise  to  the  crest,  reached  in  1874  (with  a 
rate  of  352),  was  gradual  and  broken  frequently  by  larger  and  smaller  reces¬ 
sions,  while  the  descent  was  marked  by  an  almost  continuous  fall  to  the  com¬ 
paratively  low  rate  of  130  in  1878.  During  this  whole  period  the  rates  for 
dysentery  were  low,  and  during  the  descent  of  the  wave  for  cholera  infantum 
the  curves  for  the  two  rubrics  followed  the  same  general  course.  The  rates  for 
diarrhoea,  on  the  other  hand,  continued  until  in  1871  the  very  definite  ascent 
begun  in  1861,  but  fell  decidedly  during  the  peak  of  the  wave  for  cholera 
infantum,  only  to  ascend  again  during  the  years  of  the  latter’s  decline.  The  low 
point  attained  at  the  end  of  the  fourth  wave  was  lower  than  that  of  the  third 
but  considerably  higher  than  those  of  the  first  and  second  waves.  From  1879 
to  1892  the  course  of  the  curve  for  cholera  infantum  was  fairly  even,  with 
rates  varying  between  153  and  195.  The  rates  for  diarrhoea  ascended  gradually 
to  the  highest  point  attained  in  years,  and  a  sharp  rise  in  the  rates  for  dysentery 
(1886-1890)  was  apparently  without  influence  upon  those  of  cholera  infantum. 
Between  1899  and  1907,  in  the  face  of  a  sharp  drop  in  the  rates  for  diarrhoea 
and  the  continued  descent  for  those  for  dysentery,  the  rates  for  cholera  infan¬ 
tum  completely  reversed  their  course.  Then  until  1915,  in  the  face  of  low  and 
fairly  well  stabilized  rates  for  diarrhoea  and  the  descent  of  those  for  dysentery 
to  nearly  the  vanishing-point,  the  rates  for  cholera  infantum  fell,  with  some 
fluctuations,  to  80,  the  lowest  point  recorded  in  the  city’s  history.  A  sharp 
rise  in  cholera  infantum  during  the  next  3  years  to  a  rate  of  129  and  a  decline 
in  1919  to  85  were  associated  with  corresponding  changes  in  the  rates  for 
diarrhoea.  Finally,  the  slight  rise  in  cholera  infantum  in  1920  synchronized 
with  a  similar  change  in  dysentery,  an  association  possibly  significant. 

Turning  now  to  the  consideration  of  the  annual  rates  averaged  for  5-  and 
10-year  periods,  from  1821  to  1920,  inclusive  (table  20,  graph  6),  and  making 


FEBRILE  DISEASES 


O or: 

4J(J  tJ 


Table  20. — Average  rate  of  death  by  5-  and  10-year  'periods  from  acute  inflammatory  in¬ 
fections  of  intestinal  tract ,  from  1812  to  1920,  inclusive. 


Period. 

Diarrhoea 
under2vears 
of  age. 

Diarrhoea. 

Diarrhoea 
over  2  years 
of  age. 

Total. 

Dysentery. 

Cholera. 

Typhoid 

fever. 

Total. 

By  5-year 
periods. 

By  10-year 
periods. 

By  5-year 
periods. 

By  10-year 
periods. 

By  5 -year 
periods. 

k 

r“l  <u 

cq 

By  5-year 

periods. 

By  10-year 

periods. 

By  5-year 

periods. 

By  10-year 

periods. 

By  6-year 

periods. 

L* 

cd  • 
rr  co 

?*o 

s*S 

« 

By  5-year 

periods. 

By  10-year 

periods. 

1812 

to 

15... 

12 

%  •  •  • 

383 

395 

•  •  •  • 

7 

•  •  •  » 

3 

•  •  •  * 

406 

•  •  •  • 

1816 

to 

20. . . 

27 

20 

375 

379 

402 

399 

52 

32 

8 

6 

462 

437 

1821 

to 

25... 

295 

%  •  •  • 

55 

•  •  •  • 

350 

•  •  •  • 

58 

•  •  •  • 

5 

•  •  •  • 

413 

•  •  •  • 

1826 

to 

30... 

168 

232 

43 

50 

211 

282 

31 

44 

•  •  •  • 

3 

242 

328 

1831 

to 

35. . . 

237 

%  •  •  • 

43 

t  i  «  • 

280 

•  •  •  • 

38 

•  •  •  • 

200 

*  •  •  • 

•  •  •  • 

517 

•  •  •  • 

1836 

to 

40... 

153 

195 

21 

32 

174 

227 

23 

31 

100 

4 

2 

202 

360 

1841 

to 

45... 

139 

40 

•  •  •  • 

179 

•  •  •  • 

14 

•  •  •  • 

15 

•  •  •  • 

208 

•  •  •  • 

1846 

to 

50. . . 

214 

176 

65 

53 

279 

229 

60 

37 

18 

16 

357 

282 

1851 

to 

55... 

256 

*  •  •  • 

100 

•  •  •  • 

356 

•  •  •  • 

121 

•  •  •  • 

58 

•  •  •  • 

534 

•  •  •  • 

1856 

to 

60. . . 

300 

278 

62 

81 

362 

359 

65 

93 

48 

53 

475 

505 

1861 

to 

65. . . 

197 

•  •  •  • 

68 

«  •  •  • 

265 

•  •  •  • 

25 

•  •  •  • 

82 

•  •  •  • 

373 

•  •  •  • 

1866 

to 

70... 

228 

213 

88 

78 

316 

291 

28 

27 

5 

3 

87 

85 

436 

404 

1871 

to 

75. .. 

282 

*  •  •  • 

72 

»  •  «  • 

354 

*  •  •  • 

24 

•  •  •  • 

79 

•  •  •  • 

457 

•  •  •  • 

1876 

to 

80. .. 

198 

240 

70 

71 

268 

311 

16 

20 

61 

70 

346 

402 

1881 

to 

85... 

162 

%  •  •  • 

78 

»  •  •  • 

240 

»  •  •  • 

15 

«  •  •  • 

61 

%  •  •  • 

316 

•  •  •  • 

1886 

to 

90... 

162 

162 

105 

91 

267 

253 

37 

26 

56 

58 

359 

338 

1891 

to 

95... 

136 

»  •  •  • 

109 

•  •  •  • 

245 

*  •  •  • 

14 

»  •  t  • 

49 

•  •  •  • 

309 

•  •  •  • 

1896 

to 

1900. 

120 

128 

74 

92 

194 

220 

14 

14 

39 

44 

247 

278 

1901 

to 

05. . . 

129 

«  i  •  • 

17 

•  •  •  • 

146 

•  •  •  • 

10 

36 

»  •  •  • 

191 

•  •  •  • 

1906 

to 

10. .. 

112 

120 

21 

19 

133 

139 

7 

8 

34 

35 

174 

182 

1911 

to 

15... 

90 

«  •  •  • 

15 

•  •  •  • 

105 

•  •  •  • 

3 

«  •  •  • 

23 

%  •  •  • 

131 

•  •  •  • 

1916 

to 

20... 

101 

95 

17 

16 

118 

111 

1 

2 

12 

17 

131 

131 

Graph  6  (from  table  20).  Crude  mortality  rates  from  diarrhoea,  averaged 
by  5-year  periods,  from  1812  to  1920,  inclusive. 


16 


236  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

the  necessary  allowances  for  this  arbitrary  division  in  the  time  relationships, 
a  very  clear-cut  picture  is  obtained  of  the  lethal  course  of  cholera  infantum 
during  100  years.  The  5-year  averaged  rates  fell  from  the  high  level  of  295  in 
1821-1825  to  168  in  1826-1830.  The  peak  of  a  second  wave  stands  out  in 
1831-1835  with  a  rate  of  237,  which  was  followed  by  a  gradual  decline  to  a 
rate  of  139  in  1841-1845.  A  third  wave,  with  a  gradual  rise  in  rates  during  15 
years  to  a  peak-rate  of  300  in  1856-1860,  had  receded  to  a  rate  of  197  in  1861- 
1865,  when  its  further  fall  was  arrested  by  the  beginning  of  a  fourth  wave. 
The  latter  reaching  its  crest  in  1871-1875  with  a  rate  of  282,  during  the  next 
10  years  fell  to  162,  a  level  maintained  for  the  5  years  ending  in  1890.  From 
this  point,  except  for  a  slight  rise  in  1901-1905,  there  was  an  uninterrupted 
decline  until  1911-1915,  when  the  averaged  rates  stood  at  90,  the  lowest  level 
reached.  During  the  last  5  years  the  rate  reacted  slightly  to  101. 

With  the  annual  rates  averaged  for  10-year  periods  beginning  in  1821,  the 
second  wave  above  noted  is  smoothed  out  and  by  1846-1850  the  rate  had  fallen 
from  the  initial  figure  232  in  1826-1830  to  176.  For  the  10  years  ending  in 
1860  the  high  rate  of  278  was  attained.  A  drop  in  these  rates  to  213  in  1866- 
1870  was  followed  by  a  rise  of  240  in  1876-1880.  During  the  succeeding  40 
years  the  rates  fell  steadily  and  almost  uniformly  to  95  in  1911-1920. 

The  period  ending  in  1880  marked  the  turning  point  of  the  curves  for  both 
the  5-  and  10-year  averaged  rates.  When  these  pictures  are  viewed  with  a 
critical  eye,  certain  points  stand  out  with  striking  distinctness.  Previous  to 
the  beginning  of  the  present  records  there  had  occurred  a  long  wave  of  high 
mortality  marked  by  minor  fluctuations  and  extending  to  some  date  prior  to 
1821,  which,  for  some  reason  or  reasons  not  entirely  clear,  began  to  recede 
between  1826-1830  and  1836-1840  and  reached  its  ebb  about  1841-1845.  After 
1845  there  began  a  second  long  wave  (broken  by  two  sharp  crests)  whose 
recession  began  about  1876-1880,  and  by  1891-1895  the  averaged  annual  rate 
stood  at  about  the  same  level  of  that  of  1841-1845.  These  intermediate  50 
years  witnessed  sensational  changes  in  the  lethal  force  of  this  affection.  The 
action  of  the  cause  or  causes  concerned  began  suddenly  and  attained  maximum 
intensity  between  1841-1845  and  1856-1860.  Operating  with  somewhat  less¬ 
ened  intensity  during  the  next  5  or  10  years,  they  exhibited  a  final  outburst  of 
force  between  1870  and  1880,  and,  losing  power  steadily  since  the  latter  date, 
they  have  shown  no  evidence  of  a  capacity  to  regain  their  former  vigor.  What¬ 
ever  the  character  of  these  causes,  it  is  very  clear  that,  after  losing  to  a  con¬ 
siderable  degree  about  1841-1845  the  force  which  they  had  exerted  during  a 
long  series  of  years,  they  regained  it  with  renewed  strength  after  this  date  and, 
after  holding  the  field  with  pow'er  scarcely  abated  for  about  30  years,  they  sub¬ 
sided  very  decidedly  after  1880. 

Since  over  such  long  stretches  of  time  the  data  on  which  these  crude  rates 
are  based  have  been  subject  to  such  a  variety  of  influences,  concerned  particu¬ 
larly  with  changes  in  the  birth-rate  and  in  the  death-rates  for  many  diseases 
and  resulting  marked  differences  in  the  age  distributions  of  the  population  for 
which  it  is  impossible  to  make  accurate  allowances,  it  is  important  to  seek  rates 
specific  for  age  at  least  at  different  periods.  The  results  for  the  8  census  years 
from  1850  to  1920,  inclusive,  are  presented  in  table  21.  Except  in  1900  and 
1910,  the  population  figures  used  are  only  approximations;  hence  the  rates 


FEBRILE  DISEASES 


237 


derived  may  be  regarded  as  only  relatively  accurate.  Assuming  that  they  are 
comparable  within  a  reasonably  small  degree  of  error,  it  appears  that  the  rate 
rose  from  about  3,300  in  1850  to  about  4,200  in  1860  and,  remaining  unchanged 
in  1870,  fell  by  1890  to  approximately  the  level  of  1850.  Between  1890  and 
1900  it  rose  from  about  3,400  to  about  3,700,  and  falling  to  2,700  in  1910, 
reached  the  comparatively  low  level  of  2,200  by  1920. 

From  table  22  the  influence  of  sex  and  color  upon  the  death-rate  from  cholera 
infantum  is  shown  for  both  the  first  and  the  second  year  of  life,  for  the  6  years 
1910  to  1915.  Under  the  first  year  of  age  the  rates  for  males,  both  white  and 
colored,  were  higher  than  those  for  females  in  every  year  but  one ;  in  the  second 
year  of  age  the  rates  for  males  were  higher  than  those  for  females,  in  whites  in 
4  and  in  colored  in  2  out  of  the  6  years.  For  both  years  taken  together  the 


Table  21. — Rate  of  death ,  per  100,000  living  inhabitants  under  two  years 
of  age,  from  diarrhoea  under  two  years  of  age,  calculated  on  estimated 
populations  under  two  years,  except  in  1900  and  1910  when  census 
count  was  obtainable. 


Year. 

Population 
under  2  years. 

Diarrhoea 
under  2  years 
of  age. 

Remarks. 

Deaths. 

Rate. 

1850 

12472 

407 

3263 

The  number  of  deaths  for  each 

1860 

12742 

544 

4269 

designated  year  represents  an 

1870 

14544 

617 

4242 

average  of  the  deaths  for  that 

1880 

16227 

618 

3808 

year  and  for  those  next  preced- 

1890 

18762 

646 

3443 

ing  and  following,  except  for 

1900 

20220 

759 

3754 

1920,  when  the  number  of  deaths 

1910 

19851 

543 

2735 

represents  an  average  of  the 

1920 

28902 

640 

2214 

deaths  for  1919  and  1920. 

rates  were  higher  in  males  than  in  females  in  whites  in  4  and  in  colored  in  5 
out  of  the  6  years.  The  rates  for  the  first  and  second  years  of  age  averaged 
for  the  6  years  were  for  white  males  2,660,  white  females  2,355,  colored  males 
5,197,  colored  females  4,416.  When  these  are  compared  it  is  seen  that  the  rates 
were  13  per  cent  higher  in  white  males  than  in  white  females,  18  per  cent  higher 
in  colored  males  than  in  colored  females,  95  per  cent  higher  in  colored  males 
than  in  white  males,  and  88  per  cent  higher  in  colored  females  than  in  white 
females.  The  advantage  lay  distinctly  with  the  female  over  the  male  and  with 
the  white  over  the  negro. 

Probably  always,  but  certainly  since  the  distribution  of  deaths  by  months  has 
been  recorded  (since  1860),  the  highest  monthly  mortality  rates  have  fallen  in 
the  warm  months.  July  and  August  commonly  show  the  highest  monthly  rates. 
The  monthly  rates  for  sex,  age,  and  color  are  shown  in  a  typical  year  in 
table  23.  According  to  Frick’s  calculations,  in  1850  the  proportion  of  deaths 
from  cholera  infantum  to  the  10.000  inhabitants  was  22.5  for  whites  and  10.6 
for  blacks.  Of  the  whole  number  of  deaths  in  both  races,  48  per  cent  were  in 
males  and  52  per  cent  in  females. 

In  1917,  a  typical  recent  year,  of  the  deaths  from  all  causes  in  children  in 
the  first  and  second  years  of  life  the  percentages  due  to  cholera  infantum  in  the 


238  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

former  age-group  were  for  whites  31.5,  for  negroes  26,  for  total  30.3,  and  in 
the  latter  age-group,  for  wThites  32,  for  negroes  19.2,  and  for  total  27.3. 

From  the  earliest  days  in  the  annual  reports  of  the  health  department  atten¬ 
tion  has  been  frequently  directed  to  the  enormous  mortality  from  cholera  infan- 


Table  22. — Number  of  deaths  and,  the  rate  of  death,  per  100,000  living  inhabitants  un¬ 
der  2  years  of  age,  from  diarrhoea  in  children  under  2,  according  to  age,  color,  and 
sex,  from  1910  to  1915,  inclusive  * 


D  =  death.  R  =  rate. 
TOTAL. 


White. 

Colored. 

Year. 

Male. 

Female. 

Male. 

Female. 

D 

R 

D 

R 

D 

R 

D 

R 

1910  ... 

242 

2727 

204 

2399 

104 

8374 

70 

5677 

1911  ... 

221 

2467 

235 

2736 

65 

5179 

62 

5012 

1912  ... 

197 

2178 

193 

2225 

55 

4338 

65 

5237 

1913  ... 

264 

2890 

208 

2374 

63 

4918 

54 

4337 

1914  ... 

246 

2667 

220 

2487 

60 

4637 

45 

3603 

1915  ... 

221 

2373 

171 

1914 

49 

3749 

33 

2634 

UNDER  ONE  YEAR. 


1910  ... 

208 

4634 

165 

3748 

92 

13431 

62 

9351 

1911  ... 

183 

4037 

205 

4611 

58 

8382 

54 

8120 

1912  ... 

169 

3692 

156 

3474 

51 

7296 

58 

8696 

1913  ... 

219 

4739 

183 

4035 

59 

8357 

45 

6726 

1914  ... 

207 

4436 

185 

4039 

54 

7574 

40 

5961 

1915  ... 

184 

3906 

137 

2962 

44 

6111 

27 

4012 

BETWEEN  ONE  AND  TWO  YEARS. 


1910  ... 

34 

776 

39 

951 

12 

2154 

8 

1404 

1911  ... 

38 

858 

30 

724 

7 

1243 

8 

1399 

1912  ... 

28 

626 

37 

885 

4 

703 

7 

1220 

1913  ... 

45 

997 

25 

592 

4 

696 

9 

1563 

1914  ... 

39 

856 

35 

820 

6 

1033 

5 

865 

1915  ... 

37 

804 

34 

789 

5 

852 

6 

1034 

*  The  totals  of  these  figures,  which  were  obtained  from  special  tables  in  the  annual 
reports,  do  not  correspond  with  those  given  in  the  tables  of  deaths  from  all  causes,  but 
their  proportionate  distribution  by  color  and  sex  may  be  regarded  as  relatively  accurate. 

The  population  figures  used  in  computing  rates  for  1910  are  those  furnished  by  the 
Bureau  of  the  Census.  Owing  to  peculiar  population  changes  in  connection  with  the  World 
War,  the  population  figures  used  for  1911  to  1915,  inclusive,  were  derived  by  exterpolation 
from  the  figures  for  1910  rather  than  by  interpolation  from  the  figures  for  1920. 


turn,  but  except  for  recommending  parks  and  the  planting  of  shade  trees,  no  rec¬ 
ommendations  were  made  until  very  recent  years.  While  ever  ready  to  cooperate 
with  private  agencies  in  furnishing  statistical  information,  the  health  depart¬ 
ment  has  always  confined  its  activities  to  general  measures.  The  mortality  of 
babies  from  cholera  infantum  in  the  larger  foundling  asylums  was  particularly 
heavy  until  the  last  few  years.  All  effective  efforts  of  a  specific  character  to 


FEBRILE  DISEASES 


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240  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

control  the  mortality  from  this  disease  have  been  executed  by  physicians  and 
by  certain  private  organizations.  The  medical  profession  has  always  insisted 
upon  the  importance  of  breast-feeding  over  the  second  summer  if  possible,  and 
when  this  was  impracticable  upon  the  use  of  the  best  cow’s  milk  procurable  and 
properly  modified.  For  both  prevention  and  cure,  removal  of  babies  to  the 
country  was  standard  advice  to  mothers  who  could  afford  it.  As  early  as  1870, 
William  T.  Howard,  sr.  (52),  taught  that  babies  weaned  after  April  1  rarely 
if  ever  escaped  cholera  infantum  during  the  succeeding  summer  if  kept  in  the 
city.  While  the  public  dispensaries  and  those  connected  with  various  hospitals 
had  special  services  for  children’s  diseases,  the  first  organized  pediatric  clinic 
to  undertake  in  a  truly  scientific  manner  the  prevention  and  cure  of  infantile 
diarrhoea  was  that  established  in  1889  under  the  charge  of  Dr.  William  D. 
Booker,  at  the  dispensary  of  the  Johns  Hopkins  Hospital.  Work  on  similar 
lines  was  soon  undertaken  at  the  Robert  Garrett  Hospital  under  the  direction 
of  Dr.  Walter  B.  Platt,  and  at  the  Nursery  and  Children’s  Hospital  by  Drs. 
Friedenwald  and  Buhrah.  By  1900  the  treatment  of  this  disease  had  greatly 
improved  at  all  the  dispensaries  with  children’s  clinics.  Booker  was  responsible 
for  introducing  the  practice  of  pasteurization  of  milk  for  babies  about  1892, 
the  modification  of  cow’s  milk  on  scientific  principles  for  infant  feeding  about 
1895,  and  persuading  Mr.  Samuel  M.  Shoemaker  to  establish  a  Walker-Gordon 
milk  laboratory  to  supply  pure  milk,  both  modified  and  whole  in  1900. 

The  Thomas  Wilson  Sanatorium,  the  first  endowed  philanthropic  institution 
in  the  city  to  contribute  in  a  large  way  to  the  decrease  in  the  death-rate  from 
cholera  infantum,  opened  its  summer  home  in  the  country  for  babies  ill  with 
this  disease  in  1884.  This  institution  has  ever  since  favorably  affected  the 
official  death-rate  from  cholera  infantum,  not  only  by  preventing  deaths  among 
its  patients,  but  by  the  fact  that  many  children  died  there  whose  deaths  would 
otherwise  have  occurred  in  the  city.  In  addition  to  its  other  beneficent  services 
and  hardly  of  less  importance,  it  afforded  Booker,  as  director  from  1884  to 
1898,  the  necessary  opportunity  to  pursue  the  studies  and  to  gain  the  experience 
on  which  his  qualifications  for  leadership  were  based.  On  Booker’s  pioneer 
work  all  real  advances  in  the  control  of  cholera  infantum  in  Baltimore  have 
been  based.  In  1904  the  sanatorium  established  four  milk  stations  in  the  city 
to  provide  good  milk  and  nursing  care  for  the  babies.  Milk  modified  in  a 
number  of  simple  mixtures  by  the  Walker-Gordon  laboratory  was  dispensed. 
By  1912  the  Babies  Milk  Fund  Association,  which  was  organized  in  1904  to 
operate  these  milk  stations,  substituted  for  the  distribution  of  modified  milk 
the  practice  of  teaching  mothers  to  modify  milk  in  their  homes.  In  addition  a 
number  of  welfare  clinics  were  established  for  the  oversight  of  babies  and  the 
instruction  of  mothers  in  their  feeding  and  general  care.  By  1918,  22  weekly 
clinics  were  held,  and  22  nurses  were  employed.  This  year  the  medical  direc¬ 
tors,  Dr.  J.  H.  Mason  Knox,  jr.  and  Dr.  Govan  F.  Powers,  reported  that  of  the 
5,795  children  under  3  years  of  age  that  were  under  observation  at  the  clinics, 
only  36  or  0.6  per  cent  died  of  cholera  infantum,  and  of  the  4,700  children  who 
received  nursing  supervision  alone  only  78  or  1.6  per  cent  died  of  this  disease, 
while  the  rate  for  the  remaining  children  of  this  age  in  the  city  was  something 
less  than  3  per  cent.  The  disposition  of  mothers  of  certain  race  stocks  to  nurse 
their  babies  must  have  exerted  a  considerable  influence  upon  cholera  infantum ; 


FEBRILE  DISEASES 


241 


while  for  the  earlier  years  there  is  no  definite  information  on  this  subject, 
inquiry  has  disclosed  that  mothers  among  some  races  of  more  recent  immigra¬ 
tion,  i.  e.,  Bohemians,  Italians,  Poles,  and  Polish  Jews  especially,  with  few 
exceptions  nurse  their  babies  faithfully  and  often  over  the  second  summer. 

While  cholera  infantum  or  “  summer  complaint  ”  of  young  children  has 
been — though  in  the  light  of  recent  knowledge,  probably  erroneously — con¬ 
sidered  from  time  immemorial  to  be  a  single  and  specific  disease  entity,  no 
such  claim  has  been  consistently  made  for  the  heterogeneous  collection  of  acute 
intestinal  affections  so  variously  named  as  cholera  morbus,  cramp  colic,  and 
inflammation  of  the  bowels,  and  finally  classed  together  on  the  strength  of  a 
single  symptom  under  the  statistical  nosological  rubric  (105),  diarrhoea  in 
persons  over  2  years  of  age.  In  medical  nosology  it  has  long  been  recognized 
that  these  diarrhoeas  may  be  associated  not  only  with  poisonings  with  inorganic 
substances  (arsenic,  etc.),  but  with  organic  compounds  present  in  foods — unripe 
and  spoiled  fruits  and  vegetables  in  common  use,  spoiled  meats  (including 
shellfish  and  other  fish),  spoiled  milk  and  milk  products,  polluted  waters,  and 
particularly  vegetables  and  fruits  naturally  poisonous  to  man  (certain  species 
of  mushrooms,  for  example).  The  diarrhoeas  following  the  ingestion  of  spoiled 
food,  attributed  in  the  earlier  days  of  bacteriology  to  special  poisonous  products 
produced  by  the  action  of  the  bacteria  of  putrefaction,  were  later  ascribed  partly 
or  entirely  to  infections  with  specific  bacteria  ( B .  enteritidis ,  B.paratyphosus, 
B.  coliy  etc.).  Similarly,  the  non-specific  diarrhoeas  associated  with  drinking 
polluted  waters  and  so  common  before  the  days  of  water  purification  have  been 
attributed  to  bacteria,  though  the  particular  species  of  offending  organisms  have 
not  by  any  means  been  satisfactorily  identified.  Infestion  of  the  intestine  by 
various  species  of  worms  has  been  long  recognized  as  a  cause  of  diarrhoea,  and 
similarity  in  later  years  certain  flagellate  protozoa  have  been  ascribed  causal 
roles.  It  is  probable  that  in  former  days  fatal  diarrhoeas  due  to  unrecognized 
infestion  with  trichinae  were  not  uncommon.  To  ill-prepared  and  to  scanty 
but  otherwise  healthy  foods  diarrhoeas  have  often  been  attributed.  Finally, 
there  are  diarrhoeas  believed,  apparently  with  good  reason,  to  be  due  to  disorders 
of  function  of  the  nervous  system,  of  which  the  so-called  mucous  colitis  is 
an  example. 

Since  the  beginning  of  the  local  records,  diarrhoeal  affections  of  adults  and 
of  older  children,  classified  in  both  medical  and  statistical  nosology  as  diarrhoea, 
inflammation  of  the  bowels,  cholera  morbus,  and  cramp  colic,  have  been  credited 
with  a  considerable  toll  of  deaths.  As  has  already  been  indicated,  it  is  certain 
that  until  very  recently  due  discrimination  was  not  exercised  in  the  classifica¬ 
tion  of  deaths  between  these  categories  and  cholera  infantum.  An  error  in  a 
way  even  more  serious  has  doubtless  arisen  from  the  classification  under  these 
headings  of  deaths  due  to  such  specific  diseases  as  Asiatic  or  true  cholera, 
dysentery,  typhoid  fever,  tuberculosis  (pulmonary  and  intestinal,  both  often 
associated  with  looseness  of  the  bowels),  paratyphoid  fever,  and  appendicitis. 

Diarrhoea  occupied  a  position  in  the  statistical  nosology  as  early  as  1812,  but 
did  not  appear  again  until  1820.  With  the  exception  of  1821,  1822,  and  1825, 
it  was  not  credited  with  any  considerable  number  of  deaths  until  1849,  and  in 
many  of  the  intervening  years  was  entirely  absent  from  the  list  of  the  causes 
of  death.  Indeed,  it  was  not  until  1875  that  this  term  was  given  constantly  and 


242  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

consecutively  the  leading  position  in  the  statistical  nosology  for  deaths  from 
this  group  of  affections.  Inflammation  of  the  bowels,  though  introduced  in  the 
statistical  nosology  as  early  as  1818,  did  not  attain  importance  until  20  years 
later.  During  the  fifth,  sixth,  and  seventh  decades  of  the  nineteenth  century 
it  was  a  favorite  rubric,  and  average  rates  of  30  or  over  were  recorded.  From 
1871  to  1895  the  averaged  rates  were  about  18;  and,  with  gradually  diminish¬ 
ing  rates,  it  disappeared  in  1899.  The  rates  under  this  rubric  were  but  little 
influenced  by  the  cholera  years.  Cramp  colic,  appearing  in  the  list  of  causes 
of  death  in  1812,  and  the  accredited  cause  of  a  considerable  number  of  deaths 
in  the  second,  third,  and  seventh  decades  of  the  nineteenth  century,  was 
dropped  from  the  statistical  nosology  in  1873.  Cholera  morbus  appeared  as  a 
statistical  rubric  from  1812  until  1913,  but  until  1821  carried  also  the  deaths 
from  cholera  infantum.  During  much  of  the  period  until  1873  it  was  credited 
with  relatively  high  rates.  As  elsewhere  pointed  out,  the  rates  for  this  rubric 
were  particularly  high  in  certain  cholera  years  (1834,  1849,  and  1854).  The 
relative  importance  at  different  periods  of  these  four  categories — diarrhoea, 
inflammation  of  the  bowels,  cramp  colic,  and  cholera  morbus — is  shown  in 
table  19. 

The  course  of  the  curve  of  the  annual  mortality  rates  for  this  group  of 
affections  embraced  is  the  rubric  diarrhoea  (105)  shows  considerable  fluctuation 
(graph  5),  sometimes  from  year  to  year  and  at  other  times  over  longer  or 
shorter  terms  of  years.  The  rise  and  fall  in  the  rates  vary  sometimes  directly,  or 
in  the  same  direction,  and  at  other  times  indirectly,  or  the  direction  opposite 
with  those  of  cholera  infantum  and  of  dysentery.  As  compared  with  dysentery, 
with  few  exceptions,  not  until  1850  do  high  and  low  rates  for  the  two  rubrics 
fall  in  the  same  years.  It  is  not  until  the  epidemic  wave  of  dysentery  beginning 
in  1849  that  the  courses  of  these  two  affections  really  move  closely  together. 
When  dysentery  fell  abruptly  10  years  later  diarrhoea  did  not  follow.  The  same 
phenomenon  occurred  in  connection  with  the  last  dysentery  epidemic,  1886- 
1890.  On  the  whole,  however,  the  rates  for  the  two  show  a  decided  tendency  to 
follow  the  same  course.  The  toll  of  mortality  has  been  generally  much  greater 
for  diarrhoea  than  for  dysentery.  The  correspondences  and  differences  between 
the  courses  of  the  rates  for  cholera  infantum  and  diarrhoea  have  already  been 
dwelt  upon  at  some  length.  The  decided  effect  of  cholera  upon  the  rates  for 
diarrhoea  is  apparent  in  1832,  1834,  1849,  and  1854. 

At  the  beginning  of  the  period,  though  the  rates  for  diarrhoea  were  in  general 
lower  than  later  on,  their  annual  fluctuations  were  wider  and  years  of  high 
rates  were  commonly  succeeded  by  one  or  more  years  of  low  rates.  Between 
1835  and  1841  the  annual  rates  were  consistently  low;  they  rose  gradually 
until  1849,  and  between  the  latter  date  and  1898  they  were  never  below  50  and 
rarely  below  60.  The  highest  rate  recorded  was  182  in  1854  (a  cholera  year). 
The  abrupt  fall  to  36  in  1899  in  the  rate  which  had  been  maintained  for  12 
years  at  over  100,  occurring  in  the  absence  of  any  ascertainable  changes  in  popu¬ 
lation  composition,  legislation,  general  sanitary  environment,  or  administra¬ 
tive  activity,  was  probably  due  to  changes  in  classification  of  deaths  as  between 
cholera  infantum  and  diarrhoea  and  to  the  elimination  from  the  statistical 
nosology  of  inflammation  of  the  bowels.  The  latter  heading,  once  so  important, 
but  for  the  previous  20  years  attended  by  rates  between  12  and  18,  had  probably 


FEBRILE  DISEASES 


243 


in  the  last  two  decades  of  the  nineteenth  century  carried  deaths  from  appendi¬ 
citis  and  typhilitis,  and  for  that  period  at  least  a  rate  of  from  12  to  15  could 
with  propriety  on  this  account  be  subtracted  from  the  rates  for  the  rubric 
diarrhoea. 

Thus,  it  is  evident  that  the  figures  recorded  for  deaths  under  the  headings 
embraced  in  the  rubric  diarrhoea  can  not  be  regarded  as  even  approaching 
accuracy,  for  they  are  subject  not  only  to  errors  of  classification  as  between 
diarrhoea  and  cholera  infantum,  but  include  certainly  in  some  years  deaths  from 
cholera  and  probably  in  many  years  deaths  from  other  affections,  notably  dysen¬ 
tery  (particularly  amoebic),  typhoid  fever,  and  appendicitis. 


Graph  7  (from  table  20).  Crude  mortality  rates  from  diarrhoea,  averaged 
by  10-year  periods,  from  1812  to  1920,  inclusive. 


The  curves  for  the  rates  for  diarrhoea  averaged  for  5-  and  10-year  periods 
table  20,  graphs  6  and  7)  give  perhaps  a  clearer  picture  of  the  course  of  the 
mortality  of  this  group  of  affections.  The  rates  as  averaged  for  5  years  show  a 
gradual  descent  from  55  in  1821-1825  to  21  in  1836-1840.  During  the  next 
15  years  by  gradual  steps  these  rates  rose  to  100  in  1851-1855  but  receded  to 
62  in  1856-1860.  The  rates  rose  during  the  following  10  years  to  a  second 
peak  in  1866-1870  with  a  rate  of  88.  A  descent  in  the  rates  to  70  by  1876-1880 
was  a  prelude  to  an  uninterrupted  ascent  to  the  highest  averaged  rates  attained 
at  all,  109,  for  the  quinquennium  ending  in  1895.  Ten  years  later  these  averaged 
rates  had  fallen  to  17,  a  figure  departed  from  but  slightly  during  the  remaining 
15  years.  The  rates  averaged  for  10-year  periods  show  the  same  fall  between 
1821  and  1840  writh  a  succeeding  rise  to  81  in  1851-1860,  a  level  maintained 
during  the  following  10  years.  The  moderate  fall  shown  in  the  rates  averaged 


244  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

for  the  10-year  period  1871-1880  was  succeeded  by  a  second  rise  maintained 
at  92  for  the  20  years  1881-1900.  The  sharp  fall  during  the  last  20  years 
parallels  that  shown  in  the  quinquennial  rates.  A  striking  parallel  between  the 
courses  of  these  two  curves  and  those  of  cholera  infantum  exists  up  to  1880, 
but  between  this  date  and  1900  the  former  rose  while  the  latter  fell,  and  during 
the  20  years  1901-1920  the  fall  for  diarrhoea  was  much  more  abrupt  than  that 
for  cholera  infantum.  The  divergent  courses  of  these  curves  after  1880  was 
probably  due,  as  previously  explained,  more  largely  to  changes  in  the  classifi¬ 
cation  of  deaths  as  between  those  two  rubrics  than  to  actual  variations  in  their 
respective  rates  of  mortality. 

It  is  especially  worthy  of  note  that  the  averaged  rates  for  the  quinquennial 
periods  ending  in  1840  and  1910  were  identical,  i.  e.,  21,  and  that  in  each  case 
the  low  point  was  attained  after  a  prolonged  era  of  exceptionally  high  rates, 
in  the  last  instance  covering  a  period  of  60  years.  Considered  from  this  view¬ 
point,  diarrhoea,  like  cholera  infantum,  presents  strong  evidence  of  having  run 
a  course  of  two  sharply  defined  cycles.  The  first,  beginning  perhaps  long  before 
the  date  of  this  record  (1812),  is  viewed  only  in  its  period  of  decline,  which 
covered  at  least  the  20  years  1821  to  1840.  The  second  cycle,  ranging  over  a 
period  of  70  years,  1841  to  1910,  is  in  full  view.  It  takes  the  form  of  a  pro¬ 
longed  single  wave  of  high  death-rates,  broken  at  intervals  of  from  15  to  20 
years  by  three  minor  or  subsidiary  waves,  with  the  rise  and  fall  of  the  major 
wave  almost  equally  abrupt. 

Data  for  the  influence  of  color,  sex,  and  age  upon  the  mortality  morbidity 
for  diarrhoea  are  lacking.  The  distribution  of  deaths  according  to  season  agrees 
with  that  for  cholera  infantum. 

The  prevalence  and  serious  menace  of  diarrhoea  (105)  were  never  alluded  to 
in  the  reports  of  the  health  department. 

The  field  having  been  cleared  in  this  preliminary  consideration  of  the  two 
statistical  subdivisions  of  the  diarrhoeal  affections,  the  study  of  the  force  of 
mortality  of  this  group  as  a  whole  upon  the  population  may  be  undertaken. 

By  combining  the  rates  for  cholera  infantum  and  diarrhoea  (tables  19  and 
20,  graphs  5,  6,  and  7)  the  inaccuracies  incident  in  both  divisors  and  dividends 
and  in  classification  inherent  in  calculating  rates  for  these  causes  separately 
are  largely  though  not  entirely  overcome.  Omitting  as  unnecessary  detailed 
description  of  the  courses  of  the  curves  for  annual  rates  and  for  rates  averaged 
for  5-  and  10-year  periods,  and  confining  consideration  to  a  broad  view,  certain 
important  features  stand  out  with  distinctness.  They  may  be  summarized  as 
follows : 

On  the  whole,  and  particularly  up  to  1880,  the  course  of  the  curves  is  deter¬ 
mined  by  cholera  infantum. 

Since  1812  the  curves  describe  two  long  waves,  the  first  extending  from  an 
unknown  date  to  about  1845  and  the  second  running  from  the  latter  date  to 
about  1900. 

The  highest  averaged  rates  and  the  highest  annual  rate  occurred  during  the 
peak  of  the  first  wave  and  before  1820. 

The  second  wave  reached  its  peak  (about  1860)  within  the  first  15  years  of 
the  55  years  of  its  duration.  Its  decline  was  slow  and  hesitating  until 
after  1890. 


FEBRILE  DISEASES 


245 


About  1900,  the  course  of  mortality,  having  reached  approximately  the  same 
low  level  it  had  attained  in  1845,  failed  to  run  into  a  third  wave,  but,  contrary 
to  previous  experience,  it  continued  to  decline  to  a  lower  level  than  ever  before 
registered  and  during  the  past  10  years  has  shown  a  tendency  to  stabilize 
around  a  rate  of  100. 

From  the  position  of  high  importance  occupied  during  most  of  the  period 
between  1812  and  1825  and  between  1850  and  1870,  the  affections  under  con¬ 
sideration  became  relatively  unimportant  causes  of  death  by  1915. 

DYSENTERY. 

While  the  course  of  dysentery  has  been  marked  by  rather  wide  fluctuations 
(table  19,  graph  8)  since  its  appearance  in  the  local  statistical  nosology  in 


Graph  8  (from  table  19).  Annual  crude  mortality  rates  from  diarrhoea, 
dysentery,  asiatic  cholera,  and  typhoid  fever,  from  1812  to  1920,  inclusive. 

1814,  the  variations  from  year  to  year  have  not,  in  general,  been  great.  Much 
more  characteristic  has  been  the  occurrence  of  epidemic  waves  appearing  from 
time  to  time,  in  which,  from  a  comparatively  low  basic  level,  the  rates  have 
ascended  sharply,  usually  by  uneven  steps,  during  3  or  4  years,  to  a  peak,  to 
fall  again,  often  in  the  same  irregular  fashion. 

Study  of  the  annual  rates  discloses  six  distinct  waves  of  mortality.  The 
first  wave,  starting  in  1815  and  ending  in  1824,  rose  sharply,  but  with  several 
remissions,  to  a  peak  in  1820  (111)  from  which  it  receded  to  a  low  level  in 
1824  with  a  rate  (19)  but  very  little  above  that  of  1814.  The  peak  (with  a 
rate  of  64)  of  the  second  wave,  a  very  short  one,  was  attained  in  1826,  and  the 
succeeding  rapid  decline  reached  its  low  point  (12)  in  1829.  The  third  wave, 


246  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

with  its  peak  in  1832  (58),  receded  slowly  and  irregularly  to  the  lowest 
level  (5),  yet  observed  in  1846.  The  fourth  wave,  beginning  in  1847  and  attain¬ 
ing  in  1850  the  highest  level  of  mortality  (145),  in  the  history  of  the  disease 
and  declining  sharply  in  1851,  reacted  in  1852-1854  with  rates  of  128,  136, 
and  137,  respectively.  It  then  turned  to  reach  by  hesitating  steps  the  low  point 
of  19  in  1862.  The  fifth  wave,  quite  different  in  its  course  from  its  predecessors, 
began  in  1863,  attaining  rates  around  30  in  only  4  of  the  succeeding  8  years, 
and  declined  gradually  to  the  low  level  of  12  in  1884.  The  sixth  and  last  wave, 
occupying  the  years  between  1885  and  1920,  attained  its  peak  of  49  in  1890, 
and  after  a  sharp  recession  to  a  rate  of  4  in  1891  and  an  abrupt  rise  to  24 
in  1892,  it  gradually  declined.  Since  1910  the  mortality  from  dysentery  has 


Graph  9  (from  table  20).  Crude  mortality  rates  from  diarrhoea,  dysentery, 
asiatic  cholera,  and  typhoid  fever,  averaged  by  5-year  periods,  from  1812 
to  1920,  inclusive. 

been  almost  negligible.  Years  of  conspicuously  high  death-rates  were  1820  (97), 
1850  (145),  1852  (128),  1853  (136),  and  1854  (138).  The  fourth  wave,  as 
measured  by  the  height  of  rates  registered  and  the  number  of  years  during 
which  high  rates  were  maintained,  was  by  far  the  most  severe. 

Turning  now  to  the  rates  averaged  for  5-year  periods  (table  20,  graph  9), 
three  major  epidemic  periods  (1815-1845,  1850-1880,  1885-1895),  with  their 
peaks  falling  in  the  quinquennial  periods  ending  in  1825,  1855,  and  1890, 
stand  out  with  distinctness.  The  descent  in  the  curve  of  both  the  first  and 
second  of  these  waves  is  broken  by  a  secondary  rise.  The  stationary  state  of 
the  averaged  rates  as  recorded  between  1876-1880  and  1881-1885,  and  1891- 
1895  and  1896-1900  at  about  the  same  low  level  reached  in  1841-1845  is 


FEBRILE  DISEASES 


247 


significant.  Three  waves  appear  in  the  course  of  the  curve  of  the  rates  as 
averaged  for  10-year  periods.  The  first  wave,  with  an  average  rate  of  32  for 
the  period  ending  in  1820  and  44  for  the  next  10  years,  had  receded  to  31 
by  1840.  The  second  wave,  with  its  slight  rise  in  the  rates  between  1841  and 
1850,  reached  its  high  peak  in  1851-1860  (93)  and  receded  to  27  in  1861-1870. 
The  third  wave,  reaching  abruptly  its  peak  in  1881-1890,  declined  even  more 
sharply. 

On  analysis  of  the  curves  for  the  annual  rates  averaged  for  5-  and  10-year 
periods,  certain  striking  facts  in  the  natural  history  of  dysentery  in  Baltimore 
come  to  light.  During  the  20  years  from  1816  to  1835  it  was  responsible  for 
a  considerable  mortality,  but  during  the  next  10  years  it  lost  so  greatly  in  force 
that  it  might  well  have  died  out.  Due  to  the  interpolation  of  some  cause  or 
causes  beginning  to  act  between  1847  and  1850,  the  diseases  rapidly  assumed  a 
more  important  role  than  ever  before,  and  between  1850  and  1865  it  exhibited 
an  unprecedented  virulence.  This  phase  had  entirely  subsided  by  1885,  and  but 
for  a  final  flare-up  between  1887  and  1892,  the  disease  was  well  started  on  its 
gradual  decline  to  well-nigh  extinction. 

The  whole  course  of  the  disease  during  106  years  for  which  it  can  be  followed, 
suggests  that,  while  securely  intrenched  and  able  to  retain  perennially  a  secure 
foothold,  from  time  to  time  conditions  arose  that  permitted  epidemic  outbreaks 
that  ran  very  definite  wave-like  courses.  Under  usual  conditions  the  tendency 
seems  to  have  been  to  relatively  low  rates  of  mortality. 

The  influence  of  season  upon  the  death-rates  from  dysentery  has  been 
striking.  Davidge,  Reese,  Potter,  and  others  have  recorded  that  dysentery  was 
common  and  fatal  at  Fell’s  Point  in  the  summertime  during  the  last  years  of 
the  eighteenth  and  the  early  years  of  the  nineteenth  century.  The  monthly 
distribution  of  the  deaths  from  dysentery  given  in  the  tables  of  the  annual 
reports  since  1860  shows  that  while  in  many  years  death  occurred  in  every 
month,  the  greater  number  always  occurred  in  the  summer  months. 

Concerning  the  relative  frequency  of  the  two  chief  varieties  of  dysentery,  the 
bacillary  and  the  amoebic,  there  are  no  data  before  1890,  when  the  amoebic  type, 
so  distinctive  also  in  its  anatomical  lesions,  was  first  recognized.  Though  a 
considerable  proportion  of  the  earlier  cases  studied  by  Councilman  and 
Lafleur  (57),  in  1890  and  1891  originated  elsewhere,  in  Panama,  at  sea,  in 
Sparrows  Point  near  Baltimore,  and  in  the  counties  of  Maryland,  a  large 
moiety  of  the  cases  had  never  been  out  of  the  city.  A  certain  number  of  these 
cases  were  in  stevedores  who  worked  and  lived  near  the  harbor.  Later  it  was 
observed,  chiefly  by  physicians  associated  with  the  Johns  Hopkins  Hospital, 
that  amoebic  dysentery  was  by  no  means  uncommon  among  residents  of  Balti¬ 
more  and  other  parts  of  Maryland.  There  is  no  evidence,  however,  that  this 
variety  of  dysentery  formed  a  conspicuous  proportion  of  the  dysenteries  during 
the  last  epidemic  wave,  the  peak  of  which  was  in  1890.  Amoebic  dysentery  has 
been  comparatively  rare  in  the  city  since  1900.  Since  this  date,  at  least,  it  seems 
to  have  given  place  to  the  bacillary  type.  From  the  coincidence  of  very  fatal 
malaria,  yellow  fever,  and  dysentery,  particularly  at  FelPs  Point,  during  the 
last  years  of  the  eighteenth  and  the  beginning  of  the  nineteenth  century,  with 
extensive  shipping  trade  with  the  tropics,  it  is  very  probable  that  amoebic 
dysentery  was  prevalent  at  that  time  and  never  died  out.  It  is  more  likely, 


248  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

however,  that  in  the  earlier  great  waves  of  dysentery,  and  particularly  that 
between  1850  and  1870,  the  bacillary  type  was  predominant.  At  least,  during 
this  period,  there  existed  abundant  opportunities  for  its  importation.  However, 
as  both  types  of  the  disease  are  met  with  in  temperate  as  well  as  tropical  cli¬ 
mates,  and  conditions  were  favorable  for  the  importation  and  propagation  of 
their  causal  agents,  in  the  absence  of  exact  studies  in  etiology  and  pathological 
anatomy,  no  definite  conclusion  can  be  arrived  at  in  regard  to  their  relative 
frequency  as  a  cause  of  death.  In  1850,  at  the  height  of  the  second  wave  of 
dysentery,  according  to  Frick’s  analysis,  the  disease  was  nearly  “  four  times 
more  fatal  among  the  whites  than  the  blacks,  the  numbers  being  for  the  first 
16  to  the. Id, 000  inhabitants,  and  only  4.6  for  the  latter.”  As  between  the 
sexes  the  distribution  of  fatalities  were  59  per  cent  among  males  and  41  per 
cent  among  females;  90  per  cent  of  the  whole  number  of  deaths  occurred  in 
July,  August,  and  September. 


Table  24. — Number  of  deaths  and  rate  of  death,  'per  100,000 
living  inhabitants,  from  dysentery,  according  to  age,  1850. 


Age  periods. 

Deaths. 

Rate. 

Under  1  year . 

31 

506 

1  to  4  years . 

70 

380 

5  to  9  years . 

38 

189 

0  to  9  years . 

139 

312 

10  to  19  years . 

25 

68 

20  to  29  years . 

19 

55 

30  to  39  years . 

20 

81 

40  to  49  years . 

9 

62 

50  to  59  years . 

10 

123 

60  years  and  over . 

15 

236 

Total  . 

237 

79 

Mortality  rates  specific  for  age  calculated  from  Frick’s  figures  are  given  in 
table  24.  It  will  be  noted  that  the  highest  rates  occurred  at  the  extremes  of 
life,  312  under  the  tenth  and  236  over  the  sixtieth  year.  The  excessively  high 
rate  of  506  for  the  first  year  of  life  is  striking,  and  supports  the  opinion  else¬ 
where  advanced  that  an  intimate  relation  has  existed  between  dysentery  and 
cholera  infantum  in  Baltimore.  As  regards  seasonal  distribution,  the  mortality 
from  dysentery  has  not  departed  significantly  in  late  years  from  Frick’s  find¬ 
ings.  The  reports  of  the  health  department  do  not  furnish  data  for  estimating 
the  influence  of  age,  sex,  and  color  upon  dysentery  mortality  in  recent  years. 
Morbidity  reports  are  completely  lacking. 

CHOLERA. 

According  to  the  official  records,  true  cholera  has  been  present  in  Baltimore 
in  the  7  years  1832,  1834,  1845,  1866,  1877,  and  1879  (table  19,  graph  8). 
It  will  be  noted  that  this  disease  was  not  recognized  as  present  in  any  two 
consecutive  years.  This  and  other  evidence  at  hand  supports  the  view  that  it 
rarely,  if  ever,  gained  endemic  foothold,  but  was  newly  imported  in  each  year 


FEBRILE  DISEASES 


249 


in  which  it  occurred.  However,  in  1833  and  in  1867,  each  immediately  succeed¬ 
ing  a  year  of  serious  epidemic  prevalence  of  the  disease,  the  number  of  deaths 
ascribed  to  the  common  indigenous  diarrhoeal  diseases  (cholera  morbus,  cramp 
colic,  and  cholera  infantum)  was  decidedly  greater  than  the  average  for  these 
categories.  On  the  other  hand,  as  the  same  phenomenon  commonly  occurred 
during  years  when  cholera  was  acknowledged  to  be  present,  it  was  probably 
due  to  conscious  or  unconscious  faults  of  diagnosis  and  classification,  and  in 
these  particular  years  the  hidden  cholera  present  was  probably  the  result  of 
new  importation  rather  than  the  survival  of  the  disease  over  the  cold  weather. 
However  this  may  be,  cholera  in  Baltimore  has  been  a  fortuitous  visitant,  and 
always  a  reflection  of  the  invasion  of  the  disease  to  western  Europe  and  thence 
to  America. 

From  the  known  history  of  the  affection  in  Baltimore,  it  is  clear  that  while 
in  each  of  the  great  pandemics  the  disease  reached  the  city,  only  once,  i.  e.,  in 
1832,  did  the  environmental  conditions  favorable  to  its  general  dissemination 
and  the  chance  distribution  and  propagation  of  its  causal  agent  so  fall  together 
that  epidemic  outbreak  on  a  great  scale  occurred.  As  the  environmental  con¬ 
ditions  (ready  pollution  of  at  least  a  part  of  the  water-supply — wells  and 
springs — and  access  of  myriads  of  flies  to  intestinal  discharges  and  to  food) 
were  in  those  times  particularly  favorable,  it  would  appear  that  the  city’s  rela¬ 
tively  slight  outbreaks  in  most  cholera  years  were  due  very  largely  to  lucky 
chance.  From  the  comparatively  full  accounts  given  in  the  annual  reports  of  the 
years  of  serious  epidemics  and  the  more  circumstantial  records  of  Jameson  (49) 
and  T.  H.  Buckler  (11),  it  is  possible  to  trace  the  history  of  cholera  in  Balti¬ 
more  with  some  degree  of  exactness.  That  a  visitation  of  cholera  was  inevi¬ 
table  was  apparent  to  Hr.  Jameson,  the  consulting  physician  of  the  board  of 
health,  early  in  1832.  In  his  youth  he  had  imbibed  from  his  father,  a  physician 
trained  in  Edinburgh,  the  Sydenham  doctrine  of  the  causal  relation  of  “  atmos¬ 
pheric  constitutions  ”  to  epidemic  diseases  in  general,  and  this  doctrine  domi¬ 
nated  his  thought  and  activities  throughout  his  public-health  career.  Having 
followed  closely,  through  private  correspondence  and  the  public  prints,  the 
course  of  cholera  in  Europe  in  1830  and  1831,  by  February  1832,  he  was  con¬ 
vinced  that  the  disease  was  no  exception  to  this  general  law.  He,  therefore, 
informed  the  mayor  and  board  of  health  that,  in  his  opinion,  cholera  was  neither 
importable  nor  contagious,  but  was  caused  by  a  peculiar  epidemic  constitution 
of  the  atmosphere.  Consequently,  he  held  that  the  one  thing  of  prime  impor¬ 
tance  was  to  thoroughly  clear  the  city  of  everything  that  might  contaminate  the 
atmosphere.  To  his  mind  quarantine,  isolation,  and  compulsory  hospitalization, 
as  so  generally  advocated  and  practiced,  were  useless  and  wasteful  of  money  and 
effort.  He  suggested  the  establishment  of  dispensaries  conveniently  situated 
for  the  early  treatment  of  the  poor  with  symptoms  of  cholera.  For  personal 
prophylaxis,  he  advised  temperance  and  restriction  of  diet,  with  the  avoidance 
of  fresh  fruits  and  vegetables.  Jameson’s  views  were  accepted  by  the  mayor 
and  the  board  of  health  and  all  the  measures  contrary  to  them  that  were  under¬ 
taken  were  adopted  by  an  unwilling  administration,  to  whom,  in  Jameson’s 
words,  “  prudence  dictated  the  propriety  of  deferring  to  the  wishes  of  the 
people.”  On  the  other  hand,  the  great  mass  of  the  people  were  convinced  that 
cholera  was  both  importable  and  highly  contagious,  and  on  June  7,  when  the  ship 


250  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

Brenda  arrived  from  Liverpool  after  losing  14  out  of  her  123  passengers  from 
cholera  during  her  42  days  passage,  they  voiced  the  conviction  in  no  uncertain 
terms.  The  ship,  though  then  free  from  cholera  cases,  was  held  at  the  lazaretto 
for  the  usual  ventilation  of  baggage  and  cargo,  and  the  passengers  were  detained 
under  observation  for  several  days.  On  June  26  an  ordinance  was  passed  which 
required  stringent  quarantine  of  both  persons  and  ships  arriving  from  foreign 
and  domestic  ports  where  dangerous  contagious  disease  existed.  Persons  were 
forbidden  entry  to  Baltimore  within  14  days  of  their  arrival  from  any  foreign 
country.  Jameson  afterwards  justified  his  own  opinion  by  pointing  out  that 
among  the  11,946  passengers  arriving  at  quarantine  between  May  and  Novem¬ 
ber  not  a  solitary  case  of  cholera  was  detected. 

By  July,  cholera  was  rapidly  making  its  way  towards  Baltimore  from  the 
north  and  west,  and  on  the  7th,  by  ordinance,  the  means  and  personnel  were 
provided  for  more  thorough  cleaning  of  the  streets  and  alleys,  vacant  lots, 
stables,  hogpens,  slaughterhouses,  and  other  sources  of  nuisances,  and  for 
repaving  and  flushing  the  street  gutters  and  the  liming  of  all  cesspools  and 
privies.  The  board  of  health  was  authorized  to  take  over  and  equip  properly 
for  cholera  patients  the  Maryland  Hospital  and  as  many  private  dwellings  as 
might  seem  necessary  and  to  appoint  an  apothecary  in  each  ward  to  furnish 
medicines  at  all  hours  at  the  city’s  expense  to  cholera  patients. 

Considerable  headway  was  made  in  cleaning  up  the  city  in  the  5  weeks  that 
elapsed  before  the  first  cases  of  cholera  were  recognized.  From  Jameson’s 
account  it  appears  that  his  influence  with  the  mayor  was  sufficient  to  limit 
the  number  of  cholera  hospitals  to  three.  To  one  of  these  he  attached  a  free 
dispensary.  In  addition  to  the  ward  apothecaries,  a  physician  was  appointed  in 
each  of  the  12  wards  for  the  free  treatment  of  the  poor. 

As  so  often  happens  in  epidemic  visitations,  the  earliest  cases  were  not 
recognized.  On  August  4,  a  girl  of  7  years,  who  lived  at  the  corner  of  Baltimore 
and  Liberty  streets,  in  one  of  the  best  sections  of  the  city,  died  suddenly  of  an 
affection  which  was  later  considered  to  be  cholera.  The  death  of  an  old  man  on 
the  same  day  and  the  death  several  days  later  of  a  hoy  were  afterwards  thought 
by  Jameson  to  have  been  caused  by  cholera. 

At  a  meeting  of  physicians  called  by  the  mayor  on  August  9,  while  it  was 
reported  that  diarrhoea  was  common,  but  few  of  those  present  acknowledged 
that  they  had  seen  “  cases  having  the  aspect  of  cholera  in  its  intense  stage.” 
Dr.  J ameson  reported  that  he  had  seen  cases  of  true  cholera  with  one  death  at 
one  of  the  hospitals,  and  at  his  instance  a  resolution  was  passed  declaring  that 
cholera  was  present  in  the  city.  On  August  13,  12  deaths  occurred  from 
cholera,  and  of  these  10  were  in  negroes  living  in  Buxton  Lane  or  its  neighbor¬ 
hood.  On  the  20th,  55  cases  were  reported. 

From  table  25  the  course  of  this  disease  as  expressed  by  deaths  may  be  fol¬ 
lowed  by  weeks.  It  will  be  noted  that  the  number  of  weekly  deaths  ascribed 
both  to  cholera  and  to  all  causes  rose  steadily  to  a  peak  reached  the  week  ending 
September  10  and  that  the  decline  was  rapid  and  striking  during  the  next  4 
weeks.  The  disease  about  held  its  own  between  October  10  and  16.  The  number 
of  deaths  from  cholera  during  the  third  week  of  October  was  double  that 
recorded  in  the  second  week.  After  falling  during  the  last  week  of  October  to 
the  level  reached  for  the  second  week  of  this  month,  the  number  of  deaths  rose 


FEBRILE  DISEASES 


251 


again  during  the  first  week  of  November.  After  November  5,  however,  there 
were  but  2  cholera  deaths.  The  greater  number  of  cholera  deaths  (seven-eighths) 
occurred  in  September,  and  one-seventh  of  the  whole  number  was  recorded  in 
the  7  days  between  the  4th  and  the  10th  of  this  month.  From  this  table  it  is 
evident  that  the  number  of  deaths  from  all  causes,  while  rising  and  falling 
direetly  with  the  cholera  deaths,  was,  during  August,  September,  and  October, 
relatively  much  greater  than  accounted  for  by  the  deaths  attributed  to  cholera. 
During  September,  for  instance,  the  number  of  deaths  ascribed  to  causes  other 
than  cholera  was  nearly  double  the  ordinary  number  of  deaths  for  this  month. 
It  would  appear,  then,  that  the  full  influence  of  cholera  upon  the  mortality 
during  the  epidemic  is  not  disclosed  by  the  official  figures  of  cholera  deaths. 


Table  25. — Number  of  deaths  and  weekly  annual  rate  of 
death,  per  100,000  living  inhabitants,  from  cholera 
and  all  causes,  during  the  period  of  the  cholera  epi¬ 
demic  in  1832. 


Week  ending. 

Cholera. 

All  causes. 

Deaths. 

Rate. 

Deaths. 

Rate. 

Aug.  14 . 

12 

679 

79 

4471 

20 . 

54 

3056 

127 

7187 

27 . 

121 

6848 

178 

10074 

Sept.  3 . 

170 

9621 

254 

14375 

10 . 

226 

12790 

332 

18789 

17 . 

135 

7640 

225 

12733 

24 . 

40 

2264 

116 

6565 

Oct.  1 . 

21 

1188 

89 

5037 

9 . 

12 

679 

68 

3848 

16 . 

10 

566 

52 

2943 

23 . 

25 

1415 

82 

4641 

30 . 

10 

566 

62 

3509 

Nov.  5 . 

15 

849 

66 

3735 

13 . 

1 

57 

34 

1924 

20 . 

1 

57 

34 

1924 

27 . 

•  •  • 

•  •  • 

44 

2490 

Total  . . 

853 

926 

1842 

1999 

It  has  been  pointed  out  at  the  beginning  of  this  study  that  during  183)4  the 
death-rates  for  diarrhoea  (105)  and  cholera  infantum  (104)  were  unusually 
high.  The  4  deaths  from  cholera  already  mentioned  as  occurring  early  in 
August  were  not  included  in  the  853  deaths  officially  credited  to  cholera,  and 
there  were  doubtless  many  others  in  the  same  category.  On  a  conservative 
estimate,  considerably  more  than  1  per  cent  of  the  total  population  died  of 
cholera  in  this  year. 

Cholera  attacked  211  of  the  502  inmates  of  the  almshouse,  and  of  these  133 
died.  As  the  almshouse  was  situated  without  the  city  limits,  these  deaths  were 
not  included  in  the  official  figures. 

The  records  throw  no  light  upon  how  the  disease  gained  entrance  to  the  city. 
Whether  or  not  cases  or  carriers  were  admitted  through  shipping  can  not  now 
be  decided.  At  any  rate,  there  is  little  doubt  that  the  disease  was  introduced 
17 


252  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

by  means  of  overland  communication  from  the  north  and  west,  where  it  was 
first  prevalent,  and  for  which  abundant  opportunity  was  open. 

The  first  openly  declared  cases  appeared  in  Buxton  Lane,  now  Balderston 
Street,  a  narrow  and  filthy  alley,  a  short  distance  southeast  of  Baltimore  and 
Liberty  streets  and  in  the  direct  line  of  natural  drainage  from  the  latter  point, 
where  resided  the  girl  who  died  on  August  4  of  what  Dr.  Jameson  afterwards 
regarded  as  cholera.  Buxton  Lane  was  but  a  short  distance  from  Clopton's 
Spring,  one  of  the  favorite  public  springs.  It  is  not  unlikely  that  this  spring 
was  polluted  early  in  the  epidemic  and  was  responsible,  if  not  for  the  Buxton 
Lane  cases,  at  least  for  the  numerous  cases  which,  according  to  Jameson,  later 
occurred  along  Liberty  Street  and  its  vicinity.  The  disease  subsequently  spread 
through  most  of  the  city.  In  some  places  crowded  streets  and  alleys  suffered 
most,  but  there  were  many  exceptions  to  this.  From  the  character  of  the 
epidemic,  as  judged  by  the  time  distribution  of  the  deaths  and  from  Jameson's 
allusion  to  the  gradual  spread  of  the  disease  through  the  city,  it  would  seem 
likely  that  its  chief  means  of  dissemination  was  by  means  of  the  wells  and 
public  springs,  which  perhaps  became  polluted  in  rotation  as  the  infective  agent 
was  carried  from  one  part  of  the  city  to  another  by  persons  infected  in  other 
localities.  It  is  quite  possible  tliat  the  external  water-supply  may  have  been 
infected  for  a  time  at  least.  There  was,  of  course,  ample  opportunity  for  spread 
of  the  diseases  by  means  of  flies,  which  must  have  existed  in  great  numbers.  As 
much  of  the  milk-supply  was  derived  from  cows  kept  within  the  city,  opportuni¬ 
ties  for  the  infection  of  this  article  of  food  were  peculiarly  favorable. 

There  is  no  record  of  the  whole  number  of  cases  reported,  nor  are  there  data 
regarding  the  influence  of  age,  sex,  and  color  upon  either  incidence  or  mor¬ 
tality.  According  to  Jameson,  “a  very  great  majority  of  those  who  died 
were  of  the  most  worthless;  but  a  few  of  our  respectable  citizens  fell  vic¬ 
tims  ....,''  a  blunt  way  of  saying  that  the  disease  was  more  prevalent  and 
fatal  among  the  poor  and  ill-nourished  than  among  the  well-to-do. 

Out  of  the  nearly  100  physicians  of  the  city,  a  few  had  the  disease  and  one 
died.  From  this  it  would  appear  that  the  mortality  rate  among  physicians  was 
about  the  same  as  that  for  the  population  as  a  whole.  Two  out  of  an  unknown 
number  of  Catholic  sisters,  who  acted  as  voluntary  nurses  in  cholera  hospitals, 
died  of  the  disease.  Of  the  387  cases  admitted  to  the  cholera  hospitals,  170 
died,  a  case  fatality-rate  of  44  per  cent.  However,  as  it  is  recorded  that  many 
were  moribund  on  admission  and  that  such  was  the  dread  of  the  hospitals 
that  few  who  had  homes  and  could  receive  any  attention  in  them  would  consent 
to  be  removed,  these  figures  can  not  be  taken  as  a  correct  index  of  the  propor¬ 
tion  of  cases  to  deaths  in  the  whole  population. 

From  Jameson's  account,  the  plan  of  medical  treatment  of  the  hospital 
cases — copious  blood  letting,  purging  with  calomel  and  aloes  and  croton  and 
castor  oils,  blistering  with  cantharides,  and  the  like,  was  not  calculated  to 
diminish  the  fatality  rate.  It  is  of  interest  that  following  the  lead  of  Diffen- 
bach,  of  Berlin,  and  of  certain  physicians  of  Hew  York  and  of  Norfolk, 
Virginia,  Jameson  experimented  with  intravenous  injections  of  common  salt 
and  water.  While  temporary  improvement  followed  in  some  cases,  all  patients 
so  treated  died.  His  experience  with  injections  of  plain  water  and  aqueous 
solution  of  nitrate  of  potash  was  similar. 


FEBRILE  DISEASES 


253 


The  data  concerning  the  cholera  of  1834  are  very  scanty.  Jameson  recorded 
that  a  few  doubtful  cases  occurred  in  the  summer,  but  that  in  November  there 
was  a  sudden  outbreak.  During  this  month  there  occurred  71  deaths,  the  whole 
number  recorded  for  this  year.  The  cholera  hospital  was  opened  on  November 
8  and  closed  on  December  6.  As  Jameson  regarded  the  doubtful  cases  of  the 
summer,  as  well  as  those  of  November,  as  cases  of  cholera  morbus  or  “  con¬ 
secutive  cholera  ....  made  to  assume  the  livery  of  cholera  from  a  predis¬ 
position  or  impression  left  in  the  system  by  the  epidemic  atmosphere  of  1832,” 
and  as  rates  for  diarrhoea  and  cholera  infantum  jumped,  as  in  1832,  to  unusu¬ 
ally  high  levels,  there  is  good  reason  for  the  inference  that  cholera  was  much 
more  widespread  and  fatal  in  1834  than  the  official  figures  indicate. 

The  correctness  of  the  diagnosis  in  connection  with  the  single  death  ascribed 
to  cholera  in  1845  is  open  to  question.  No  mention  was  made  in  the  annual 
report  of  the  presence  of  this  disease  in  the  city  or  at  the  quarantine  station, 
and  there  was  no  significant  change  in  the  rates  for  the  diarrhceal  affections. 

Cholera  was  undoubtedly  prevalent  to  some  extent  within  the  city  in  1849, 
though  no  deaths  were  credited  to  it,  and  no  allusion  was  made  to  the  disease 
in  the  annual  report  of  the  health  department. 

T.  H.  Buckler  (11)  wrote  a  very  complete  account  of  a  serious  epidemic  of 
cholera  at  the  almshouse  in  1849.  The  first  case  occurred  on  July  1  and  the 
last  on  August  8;  the  first  death  took  place  on  July  11  and  the  last  on 
August  5.  During  the  first  two  weeks  the  progress  of  the  disease  was  slow 
and  hesitating  (single  cases  on  July  1  and  7,  3  each  on  the  11th  and  12th, 
and  1  case  on  the  13th).  The  peak  came  abruptly  and  lasted  10  days  with 
relatively  little  daily  variation  in  the  number  of  cases  (13  cases  on  the  14th 
and  a  daily  average  of  10  new  cases  from  the  15th  to  the  24th).  The  decline 
was  as  sharp  and  as  long  drawn  out  as  the  approach  (3  cases  on  the  25th  and, 
with  the  exception  of  4  cases  on  the  27th  and  5  on  the  30th,  never  more  than 
3  a  day,  and  a  total  of  8  cases  between  August  1  and  8).  The  distribution  of 
deaths  according  to  days  followed  that  of  the  cases  very  closely  during  the 
height  of  the  epidemic. 

The  population  of  the  almshouse  when  cholera  broke  out  was  560,  of  whom 
407  were  whites  and  153  blacks;  but  during  the  epidemic  there  were  109 
admissions  and  153  emissions.  The  latter  embraced  56  discharges,  76  elope¬ 
ments,  and  21  dead  from  causes  other  than  cholera.  Altogether,  669  individ¬ 
uals  were  exposed  to  risk  of  attack  and  death  from  cholera,  but  their  degree  of 
exposure  was  not  the  same.  On  this  account  it  is  not  possible  to  calculate 
precise  morbidity  and  mortality  rates.  There  were  recognized  155  cases  of  true 
cholera;  of  these  86  died,  and  on  the  basis  of  a  population  of  669  exposed  in 
some  degree,  the  attack  and  mortality  rates  were  23  per  cent  and  12.8  per  cent 
respectively.  Among  the  whites  there  were  112  cases  with  57  deaths  and  among 
the  negroes  43  cases  with  29  deaths ;  thus  the  case  fatality  rates  were :  Whites 
50  per  cent,  negroes  67  per  cent,  total  55.5  per  cent.  However,  according  to 
Buckler,  the  number  of  each  sex  admitted,  discharged,  and  eloped  during  July 
bore  a  very  uniform  ratio  to  the  proportion  of  males  and  females  present  at 
the  beginning  of  the  month.  On  the  female  side  of  the  institution  there  were 
on  July  1,  322,  and  in  this  department  62  had  cholera  and  38  died;  the  males 
at  the  same  date  numbered  238,  and  on  this  side  there  were  93  cases  of  cholera. 


254  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

with  48  deaths.  Using  these  figures  as  a  basis,  the  attack,  death,  and  case- 
fatality  rates  were:  For  females  19  per  cent,  11  per  cent  and  G1  per  cent,  and 
for  males  39  per  cent,  20  per  cent,  and  50  per  cent,  respectively.  According  to 
these  approximate  figures,  the  attack  and  death  rates  were  twice  as  great  in 
males  as  in  females,  and  the  case  fatality  was  somewhat  higher  in  females  than 
in  males. 

As  from  Buckler’s  account  it  is  probable  that  the  infection  was  not  spread 
by  the  water-supply  derived  from  a  nearby  stream  called  Rutter’s  Run,  at  a 
point  above  the  institution,  but  rather  by  personal  contact  and  by  flies,  since 
the  disease  was  not  uniformly  distributed  throughout  the  institution  and  the 
great  bulk  of  the  cases  developed  among  those  who  were  housed  in  the  wings 
facing  north  and  east  and  directly  overlooking  a  huge  open  cesspool  which 
received  all  the  drainage.  Draining  and  cleaning  the  cesspool  by  ditching  and 
flushing  was  started  on  July  23  and  finished  on  the  25th,  the  date  of  the 
beginning  of  the  decline  in  the  attack  rate.  Three  days  later  the  whole  area 
of  this  pond  of  fecal  discharge  was  covered  with  several  bushels  of  unslaked 
lime  overlay  ed  with  fresh  earth,  and  after  July  28  only  18  additional  cases 
occurred.  Two  of  the  three  laborers  employed  in  this  work  developed  cholera 
on  July  29  at  their  homes  in  the  city.  According  to  the  fashion  of  the  day, 
Buckler  attributed  the  outbreak  to  miasma  from  the  open  cesspool. 

Though  not  officially  recognized,  cholera  was  certainly  present  in  the  city 
during  this  year.  Besides  the  two  laborers  above  mentioned,  Buckler  saw  3 
cases  late  in  July  and  on  September  15  attended  another  case  in  a  man  who 
was  taken  sick  shortly  after  arriving  from  Cincinnati.  According  to  him,  a 
mild  “  cholorine  ”  prevailed  during  the  summer  in  nearly  every  section  of  the 
city.  Though  no  deaths  were  recorded  from  cholera,  the  death  rates  from 
diarrhoea  and  cholera  infantum  were  conspicuously  higher  than  during  the 
previous  year. 

No  cases  of  cholera  were  discovered  on  ships  arriving  at  quarantine.  It  is 
certain  that  the  disease  was  brought  in  by  overland  travelers  at  least  once  during 
the  year,  and  it  is  probable  that  sporadic  cases  secondary  to  imported  cases 
occurred  widely  during  the  hot  weather.  The  disease  was  probably  introduced 
into  the  almshouse  by  a  pauper  from  the  city.  That  the  city  escaped  a  wide¬ 
spread  water-borne  epidemic  is  due  to  the  fact  that  Rutter’s  Run,  into  which 
the  almshouse  cesspool  drained,  was  a  tributary  of  Gwynn’s  and  not  of  Jones 
Falls. 

In  1854,  a  few  sporadic  cases  of  cholera,  with  2  deaths,  were  acknowledged 
by  the  health  department.  These  were  regarded  as  secondary  to  a  small  out¬ 
break  just  without  the  western  border  of  the  city.  One  case  of  cholera  was 
recorded  at  the  Marine  Hospital,  but  this  was  possibly  received  from  the  city. 
In  this  year  not  only  were  deaths  from  the  diarrhoea!  diseases  considerably 
higher  than  during  the  preceding  year,  but  the  increase  was  most  marked  in 
the  categories  most  likely  to  hide  cholera,  namely,  cholera  morbus  and  cramp 
colic.  In  1854,  the  deaths  from  the  former  were  129  and  from  the  latter  111, 
in  contrast  to  11  and  28,  respectively,  in  1853.  The  total  rate  for  diarrhoea 
was  182,  or  more  than  double  the  rates  for  1853  and  1855.  There  is  ample 
reason,  therefore,  for  the  inference  that  cholera  was  epidemic  in  the  city  in 
1854  and  was  responsible  for  a  death-rate  of  at  least  100. 


FEBRILE  DISEASES 


255 


Judging  from  the  monthly  distribution  of  the  recorded  deaths  from  the 
disease,  54  in  October  and  6  in  November,  the  outbreak  of  recognized  cholera 
in  1866  probably  began  after  the  middle  of  September.  It  is  unlikely,  however, 
that  this  disease  was  more  widely  spread  and  fatal  than  the  official  figures 
indicate,  for  the  death-rates  from  both  cholera  infantum  and  diarrhoea  were  not 
significantly  higher  than  in  the  years  immediately  preceding.  Though  cholera 
approached  the  city  by  water,  a  case  being  removed  from  a  vessel  at  quarantine 
during  the  summer,  the  health  authorities  were  perhaps  correct  in  their  asser¬ 
tion  that  the  first  cases  came  overland,  one  from  New  York  and  the  other 
from  Cincinnati.  Their  attitude  towards  the  disease  was  quite  different  now. 
Theories  of  “  atmospheric  constitutions  ”  and  of  miasma  no  longer  befogged' 
their  minds.  Snow’s  discovery  of  some  16  years  before  that  epidemic  cholera 
was  largely  ^waterborne,  and  the  popular  view  that  the  disease  might  be  con¬ 
veyed  somehow  by  personal  relation  with  cholera  patients,  were  taken  seriously. 
Action  direct  and  personal  became  the  order  of  the  day;  the  sick  and  their 
discharges,  clothing,  and  utensils  were  recognized  as  vehicles  by  which  the 
mysterious  cause  was  disseminated.  Measures  were  adopted  to  secure  the 
removal  and  destruction  of  everything  used  by  those  affected  with  the  disease, 
and  the  disinfection  and  burial  of  their  discharges.  In  appropriate  instances 
both  the  sick  and  the  exposed  were  removed  to  the  quarantine  hospital. 

“  In  Elbow  Lane,  in  one  square,  20  cases  occurred  in  2  days ;  the  crowded  condi¬ 
tions  of  the  houses,  the  filth  of  the  houses  and  of  the  people  (negroes)  we  thought 
justified  extreme  measures.  Every  person,  both  sick  and  well,  was  removed  to  the 
quarantine  grounds,  the  sick  put  in  the  hospital  and  the  others  in  barracks.  Not  a  single 
case  occurred  after  removal,  either  in  the  alley  or  in  the  removed  persons.  But  one  of 
those  attacked  recovered.” 

Everything  used  by  the  sick  was  destroyed,  the  houses  were  fumigated,  and 
after  10  days  the  well  people  were  allowed  to  return;  no  subsequent  cases 
occurred  in  this  group. 

No  allusion  is  made  to  cholera  in  the  annual  reports  for  1877  and  1879. 
From  the  comparatively  small  number  of  deaths  and  the  absence  of  any  striking 
increase  in  the  rates  from  diarrhoea  and  cholera  infantum,  it  is  probable  that 
the  disease  was  confined  to  a  few  sporadic  cases.  No  cases  were  discovered  in 
connection  with  shipping. 

Unfortunately,  for  none  of  the  cholera  years  is  there  any  record  of  the  number 
of  cases  or  of  the  distribution  of  the  deaths  according  to  the  age,  sex,  or  color 
of  the  decedents. 

Thus  runs  the  history  of  cholera  in  Baltimore.  Though  incomplete  in  many 
details,  it  is  sufficiently  accurate  for  a  fairly  correct  picture.  Attention  may 
here  be  directed  to  certain  points  of  particular  importance.  While  the  official 
figures  of  deaths  ascribed  to  cholera  are  probably  lower  than  the  actual  number 
of  deaths  from  this  disease  in  every  year  in  which  cholera  occurred,  they  are 
particularly  far  short  of  the  truth  for  1849  and  1854.  In  these  two  years,  at 
least,  the  health  authorities  deliberately  sought  to  hide  the  truth.  The  great 
influence  of  cholera  in  1832  and  1834  upon  the  total  death-rate  from  acute 
intestinal  diseases  for  the  quinquennium  1831-1835  and  the  decennium  1831- 
1840  is  shown  by  the  fact  that  by  the  official  figures  alone  the  cholera  deaths, 
raised  the  averaged  rates  for  the  former  period  by  200  and  for  the  latter  period 
by  100.  If,  for  the  period,  1831-1835,  all  the  deaths  really  due  to  cholera  but 


256  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

which  were  credited  to  cholera  infantum  and  diarrhoea  could  be  properly  classi¬ 
fied,  it  would  appear  that,  but  for  the  advent  of  cholera,  the  decline  in  the  total 
rate  for  the  acute  intestinal  diseases  would  have  been  unbroken.  As  it  is,  when 
the  rates  for  cholera  calculated  from  the  official  figures,  without  such  allowance, 
are  subtracted  from  the  rates  averaged  for  the  10  years  1831-1840,  the  decline 
in  the  curve  is  almost  continuous.  Similarly,  a  not  inconsiderable  portion  of 
the  ascent  in  the  total  rates  for  acute  intestinal  affections  between  1849  and 
1860  was  due  to  the  influence  of  cholera  in  1849  and  1854. 

On  the  whole,  in  comparison  with  certain  other  cities,  Baltimore’s  experience 
with  cholera  was  not  unlucky.  In  but  one  year,  1832,  was  the  toll  from  cholera 
relatively  serious. 

TYPHOID  FEVER. 

The  term  typhoid  fever  did  not  appear  in  the  local  statistical  nosology  until 
1851.  However,  there  is  convincing  evidence  that  the  disease  was  not  uncommon 
in  the  city  long  before  this  date.  The  report  of  the  attending  physicians  of  the 
almshouse  infirmary  in  1828  mentions  58  cases  of  fehris  typhoides,  with  13 
deaths.  Typhoid  fever  was  credited  in  these  reports  with  cases  and  deaths 
every  year  but  one  between  1833  and  1849,  and  during  these  17  years  there  was 
a  total  of  359  cases  with  106  deaths.  E.  Geddings  (58),  under  the  title  of 
“  gastric,  or  more  properly  intestinal  fever,”  described  a  continuous  fever  of 
grave  type  which  was  very  prevalent  in  1834;  80  casese  were  admitted  to  the 
Baltimore  Infirmary  during  the  summer  of  this  year.  It  was  especially  common 
at  EelPs  Point,  and  many  of  the  patients  were  sailors  who  were  attacked  after 
their  arrival.  Some  of  the  victims  were  brought  in  from  the  nearby  rural 
districts.  From  Gedding’s  description  of  the  clinical  symptoms  and  of  the 
ulcers  of  the  small  intestine  in  fatal  cases,  there  can  be  little  doubt  that  he  was 
dealing  with  true  typhoid  fever.  It  would  also  appear  that  gastric  fever  was 
commonly  used  as  a  synonym  for  typhoid  fever. 

Buckler  (11)  is  authority  for  the  statement  that  typhoid  fever  was  very 
prevalent  in  grave  form  among  the  inmates,  resident  physicians,  and  students 
at  the  almshouse  between  1846  and  1849  inclusive.  During  the  last  three  of 
these  years  the  wards  were  never  free  from  cases.  In  1847,  Frank  Donaldson 
demonstrated  the  intestinal  lesions  of  typhoid  fever  in  an  immigrant  dying  at 
the  Marine  Hospital,  and  sent  to  the  almshouse  infirmary  2  cases  of  the  disease 
removed  from  ships.  The  annual  reports  of  the  quarantine  officer  about  this 
date  and  later  mention  not  infrequently  cases  of  this  affection. 

There  were  not  lacking  in  Baltimore  in  1840  able  physicians,  who  were 
familiar  with  the  natural  history  of  typhoid  fever.  Among  them  were  Professor 
Elisha  Bartlett,  who  wrote  his  epochal  book  on  Continued  fevers  here  in  1842, 
Professor  William  Power,  a  pupil  of  Louis,  and  Thomas  H.  Buckler.  The 
presence  of  this  disease  in  Baltimore  as  early  as  1812  is  attested  by  the  use  of 
the  term  nervous  fever ,  the  old  German  name  for  typhoid  fever,  in  the  statisti¬ 
cal  nosology.  It  is  not  unlikely  that  the  few  cases  of  typhus  mitior  mentioned 
in  the  reports  of  the  censors  of  the  Medical  and  Chirurgical  Faculty  in  1809 
and  1811  were  typhoid  fever. 

When  typhoid  fever  first  made  its  appearance  in  Baltimore  can  not  be 
ascertained.  It  is  likely  that  it  gained  a  foothold  at  an  early  date  and  became 
gradually  more  prevalent  during  the  period  of  enormous  growth  of  the  city 


FEBRILE  DISEASES 


257 


between  1790  and  1830.  From  the  increasing  prevalence  of  the  disease  at  the 
almshouse  after  1845,  and  the  first  mention  of  cases  in  connection  with  shipping 
about  this  time,  it  is  likely  that  it  w'as  imported  on  a  large  scale  by  the  immi¬ 
grants  who  poured  in  from  Ireland  and  Germany  between  1845  and  1860. 
It  was  doubtless  very  largely  confused  with  malarial  and  typhus  fevers,  and 
between  1812  and  1850  was  probably  hidden  in  the  statistical  nosology  under 
these  headings  as  well  as  under  nervous  and  gastric  fevers  and  inflammation 
of  the  bowels.  While  up  to  1850  the  course  of  the  disease  can  be  traced  but 
imperfectly  as  nervous  and  gastric  fevers,  after  this  date  it  can  be  followed  with 
some  degree  of  accuracy.  Typhus  fever  probably,  and  malaria,  inflammation 
of  the  bowels,  diarrhoea,  and  gastric  fever  certainly,  continued  for  some  time 
to  be  credited  with  deaths  due  to  typhoid  fever.  To  make  allowance  for  evident 
statistical  errors  of  this  nature,  deaths  from  nervous,  gastric,  and  typho-malarial 
fevers  have  been  included  in  the  list  of  typhoid-fever  deaths.  Deaths  credited 
to  typhus  fever,  negligible  after  1860,  diarrhoea,  and  inflammation  of  the  bowels 
can  not  be  so  adjusted. 

On  the  other  hand,  many  deaths  from  other  causes  have  been  erroneously 
classified  under  typhoid  fever.  The  more  common  of  these  are  pneumonia, 
pleurisy,  empyema,  influenza,  appendicitis,  suppurative  processes  of  the  liver 
and  of  the  biliary  and  urinary  tracts,  acute  miliary  tuberculosis,  various  cryp¬ 
togenic  suppurative  infections,  acute  endocarditis,  pyemia,  and  septicemia — 
the  large  group  of  affections  often  included  under  the  term  typhoid  state. 
Conversely,  deaths  from  typhoid  fever  have  been  credited  to  these.  A  decidedly 
unfavorable  influence  upon  the  Baltimore  mortality  rate  from  typhoid  fever 
has  been  exerted  by  the  deaths  of  non-residents,  particularly  from  rural  Mary¬ 
land,  brought  to  the  city  for  treatment.  During  1917  to  1919,  inclusive,  such 
persons  were  responsible  for  20  per  cent  of  the  recorded  deaths  from  this  disease. 
Though  the  data  upon  which  the  mortality  rates  for  typhoid  fever  are  calculated 
are  by  no  means  exact,  the  rates  probably  approximate  the  truth  closely  enough 
to  indicate  the  general  trend  of  the  curve  of  mortality  during  the  period  under 
consideration. 

From  table  19  it  is  seen  that  there  were  deaths  recorded  from  nervous  fever 
in  each  year  but  two  from  1812  to  1824  and  in  every  year  from  1843  to  1845 
and  from  1848  to  1850  inclusive.  Deaths  were  ascribed  to  gastric  fever  from 
1837  to  1875  and  1878  to  1884  inclusive,  and  again  in  1886.  Typho-malarial 
fever,  occurring  first  in  1876,  was  given  as  a  cause  of  death  from  1879  to  1898 
inclusive.  It  is  strange  that  gastric  fever,  which  according  to  Geddings  was 
a  prevalent  and  fatal  disease  within  the  city  in  1834,  was  not  credited  with 
deaths  before  1837. 

From  the  annual  rates  (table  19,  graph  8)  it  is  evident  that  typhoid  fever 
as  nervous  fever  was  the  cause  of  a  not  inconsiderable  but  fluctuating  annual 
mortality  between  1812  and  1824.  Between  1825  and  1836  there  is  a  complete 
absence  of  deaths  ascribed  to  known  synonyms  of  typhoid  fever.  The  compara¬ 
tively  low  annual  rates  from  1837  to  1842  are  based  on  deaths  recorded  under 
gastric  fever.  Between  1843  and  1850  there  was  a  considerable  rise  in  the 
rates  for  gastric  fever,  and  in  all  but  two  years  a  few  deaths  were  credited  to 
nervous  fever.  The  highest  rate  so  far  attained  was  27,  in  1845.  After  1850, 
with  the  appearance  of  typhoid  fever  in  the  nosology,  the  rates  for  gastric 


258  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

fever  underwent  a  sudden  and  permanent  fall.  The  entrance  of  the  term 
typhoid  fever  into  the  statistical  nosology  in  1851  was  marked  by  an  increase 
in  the  rate  by  165  per  cent  over  the  previous  year.  Rising  from  53  in  1851  and 
1852  to  67  in  1853,  the  annual  rates  fell  gradually  to  42  in  1856.  By  1860 
the  rates  had  risen  to  the  level  of  1851,  and,  continuing  their  ascent,  they 
reached  80  in  1861  and  94  in  1862.  Remaining  high,  but  with  considerable 
fluctuations  from  year  to  year,  the  annual  rates  attained  their  highest  point, 
106,  in  1870.  After  this  date  the  annual  rates  declined  slowly  and  hesitatingly, 
sometimes  with  but  slight  variation,  for  a  period  of  several  years,  and  now  and 
again  with  sharp  rises  and  declines.  By  1886  the  rates  had  fallen  to  the  level 
of  1851.  After  remaining  at  about  52  for  4  years,  there  was  another  period  of 
fluctuation  lasting  until  1895.  After  stabilizing  around  40  for  4  years,  the 
rates  descended  again,  and  by  1901  had  reached  27.  From  this  point  there 
was  a  sharp  reaction  covering  the  next  8  years,  during  which  the  rates  reached 
42  in  two  years.  In  1909  the  rate  dropped  to  24.  In  1910  there  was  a  reaction 
to  41,  succeeded  by  a  fall  to  26  in  1911.  During  the  succeeding  4  years  the 
rates  were  almost  stationary  at  an  average  rate  of  22.  From  1916  the  rates 
fell  continuously,  and  at  a  more  rapid  rate  each  succeeding  year,  to  5  in  1920. 

In  studying  the  curve  of  the  rates  averaged  for  5-year  periods  (table  20, 
graph  9),  the  periods  before  1835  may  be  disregarded.  Beginning  with  a  rate 
of  4  for  the  quinquennium  ending  in  1840,  the  rates  rose  rapidly  during  the 
next  15  years  and  had  attained  58  by  1851-1855.  After  a  drop  to  48  for  the 
period  ending  in  1860  there  was  a  jump  to  82  in  1861-1865,  and  87  was 
reached  in  1870.  From  this  high  peak  the  rates  declined  sharply  during  the 
next  10  years  to  61.  After  remaining  practically  stationary  between  1876- 
1880  and  1881-1885,  there  was  a  somewhat  uneven  decline  to  12  in  1916-1920. 

For  the  rates  as  averaged  for  10-year  periods  (table  20,  graph  10),  the  curve 
is  so  smoothed  that  the  rise  in  the  rates  from  1841-1850  to  a  peak  in  1861-1870 
and  the  fall  afterwards  are  both  continuous.  The  angle  of  the  ascent  is,  however, 
much  more  acute  than  that  of  the  descent.  The  rate  of  the  fall  for  the  30  years, 
1870  to  1900,  was  fairly  even.  It  slowed  up  materially  for  the  next  10  years, 
but  between  1910  and  1920  it  was  considerable. 

On  comparing  the  curves  for  typhoid  fever  and  for  dysentery  and  diarrhoea, 
on  the  basis  of  the  annual  rates  averaged  for  5-year  periods,  it  is  observed  that 
between  1815  and  1830  the  three  rose  and  fell  together,  and  the  correspondence 
in  the  shape  of  the  curves  for  typhoid  and  dysentery  is  remarkably  close. 
Between  1840  and  1855  the  three  again  rose  together,  and  all  reached  a  peak 
in  the  latter  year.  They  fell  together  between  1855  and  1860.  While  typhoid 
and  diarrhoea  reacted  to  another  peak  attained  in  1866-1870  and  fell  together 
during  the  succeeding  10  years,  dysentery  fell  decidedly  between  1860  and  1865, 
reacted  only  slightly  in  1866-1870,  and  then  fell  continuously  and  sharply 
until  1886-1890.  On  the  other  hand,  when  diarrhoea  began  in  1890  a  sharp 
rise  which  culminated  in  1891-1895,  and  dysentery  rose  to  a  peak  in  1886-1890, 
typhoid  fever  pursued  its  gradual  decline  uninterruptedly.  The  considerable 
fall  in  the  rates  for  diarrhoea  and  dysentery  which  occurred  between  1900  and 
1910  were  not  associated  with  a  correspondingly  acute  fall  in  the  rate  for 
typhoid  fever.  In  a  general  way,  therefore,  the  courses  of  the  curves  for  these 
three  acute  intestinal  diseases  of  different  etiology  but  with  the  same  modes 


FEBRILE  DISEASES 


259 


of  spread  are  rather  closely  alike  during  some  parts  of  the  period  under  con¬ 
sideration;  at  others  they  deviate  widely. 

Data  are  available  from  1889  to  1919,  inclusive,  for  calculating  mortality 
rates  according  to  color  and  sex.  These  are  set  forth  in  table  26.  The  rates  for 
the  white  population  follow  closely  those  for  the  whole  population,  but  those 
for  the  former  exceed  those  for  the  latter  slightly  in  1893,  and  the  rates  for 
the  two  are  equal  in  7  years — in  1892,  1896,  1897,  1908,  1912,  1916,  and  1919. 
The  white  rates  are  lower  than  the  negro  rates,  except  in  1893  and  1896,  and 
the  rates  for  the  two  races  are  equal  in  1892,  1908,  and  1916.  The  rates  for 
white  females  exceed  those  for  the  males  and  for  the  whole  population  in  1892 


YEAR 

Graph  10  (from  table  20).  Crude  mortality  rates  from  diarrhoea,  dysen¬ 
tery,  asiatic  cholera  and  typhoid  fever,  averaged  by  10-year  periods,  from 
1812  to  1920,  inclusive. 

and  1893,  are  decidedly  lower  than  the  other  two  after  1894,  and  in  general 
follow  closely  the  rise  and  fall  of  the  other  rates,  particularly  those  for  total 
white  and  the  total  population.  The  rates  for  white  males,  except  in  1892  and 
1893,  are  uniformly  higher  than  those  for  white  females  and  for  the  total 
white  population. 

The  annual  fluctuations  in  the  rates  for  colored  are  much  greater  than  in 
those  for  the  white  population,  and  therefore  the  courses  of  their  curves  are 
much  less  smooth.  The  curve  for  the  total  negro  rate  falls  considerably  below 
those  for  the  whole  population  and  for  the  whites  in  1893,  but  otherwise  it 
is  considerably  higher.  The  rates  for  negro  females  are  much  lower  than  those 
for  negro  males,  except  in  1891,  1893,  1901,  and  1913,  when  the  converse 
is  true. 


260  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


It  is  clear  that  the  mortality  rates  for  typhoid  fever  have  been  markedly 
influenced  by  race  and  sex.  Since  the  rates  for  the  negro  population  are  much 
higher  than  those  for  the  white,  and  the  rates  for  females  of  both  races  are 
lower  than  those  for  males,  the  total  rate  is  influenced  favorably  by  a  low 
proportion  of  negroes  and  high  proportion  of  females  in  the  population. 

The  age  distribution  of  the  deaths  from  typhoid  in  1910  is  given  in  table  27. 


Table  26. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from 
typhoid  fever,  according  to  color  and  sex,  from  1889  to  1920,  inclusive. 


D  =  death.  R  =  rate. 


Year. 

Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1889 

•  •  •  • 

224 

52 

111 

55 

113 

50 

181 

50 

88 

51 

93 

49 

43 

66 

23 

81 

20 

55 

1890 

•  •  •  • 

301 

69 

161 

78 

140 

61 

244 

66 

135 

76 

109 

57 

57 

86 

26 

90 

31 

84 

1891 

•  •  •  • 

189 

43 

95 

45 

94 

40 

157 

42 

82 

46 

75 

38 

32 

48 

13 

44 

19 

51 

1892 

•  •  •  • 

226 

50 

100 

47 

117 

49 

192 

50 

90 

49 

102 

51 

34 

50 

19 

63 

15 

39 

1893 

•  •  •  • 

255 

56 

119 

55 

136 

57 

228 

59 

108 

58 

120 

60 

27 

39 

11 

36 

16 

41 

1894 

•  •  •  • 

257 

55 

126 

57 

131 

54 

207 

53 

103 

54 

104 

51 

50 

71 

23 

74 

27 

69 

1895 

•  •  •  • 

192 

41 

103 

46 

89 

36 

157 

39 

82 

43 

75 

36 

35 

49 

21 

66 

14 

35 

1896 

•  •  •  • 

204 

43 

109 

48 

95 

38 

174 

43 

93 

48 

81 

39 

30 

41 

16 

49 

14 

34 

1897 

•  •  •  • 

209 

43 

119 

51 

90 

35 

175 

43 

99 

50 

76 

36 

34 

46 

20 

61 

14 

34 

1898 

•  •  •  • 

201 

41 

115 

49 

86 

33 

158 

38 

96 

48 

62 

29 

43 

57 

19 

57 

24 

57 

1899 

•  •  •  • 

153 

31 

85 

36 

68 

26 

119 

28 

67 

33 

52 

24 

34 

44 

18 

53 

16 

38 

1900 

•  •  •  • 

189 

37 

104 

43 

85 

32 

152 

35 

83 

40 

69 

31 

37 

48 

21 

61 

16 

37 

1901 

•  •  •  • 

141 

27 

77 

31 

64 

24 

110 

25 

66 

31 

44 

20 

31 

39 

11 

31 

20 

46 

1902 

•  •  •  • 

220 

42 

123 

50 

97 

36 

172 

39 

99 

46 

73 

32 

48 

60 

24 

67 

24 

54 

1903 

•  •  •  • 

189 

36 

105 

41 

84 

31 

137 

31 

79 

36 

58 

25 

52 

64 

26 

71 

26 

58 

1904 

•  •  •  • 

199 

37 

117 

46 

82 

30 

158 

35 

91 

41 

67 

29 

41 

50 

26 

70 

15 

33 

1905 

•  •  •  • 

197 

36 

108 

42 

89 

32 

158 

35 

85 

38 

73 

31 

39 

47 

23 

61 

16 

35 

1906 

•  •  •  • 

183 

33 

108 

41 

75 

26 

141 

31 

83 

37 

58 

24 

42 

49 

25 

65 

17 

36 

1907 

•  •  •  • 

230 

42 

139 

52 

91 

32 

180 

39 

112 

49 

68 

28 

50 

58 

27 

70 

23 

49 

1908 

•  •  •  • 

180 

32 

103 

38 

77 

27 

152 

32 

84 

36 

68 

28 

28 

32 

19 

48 

9 

19 

1909 

•  •  •  • 

136 

24 

85 

31 

51 

17 

107 

22 

67 

29 

40 

16 

29 

33 

18 

45 

11 

23 

1910 

•  •  •  • 

235 

41 

124 

45 

111 

38 

192 

40 

101 

43 

91 

37 

43 

48 

23 

57 

20 

41 

1911 

•  •  •  • 

154 

27 

94 

34 

60 

20 

124 

25 

79 

33 

45 

18 

30 

33 

15 

36 

15 

30 

1912 

•  •  •  • 

136 

23 

72 

25 

64 

21 

111 

23 

60 

25 

51 

20 

25 

27 

12 

29 

13 

26 

1913 

•  •  •  • 

135 

23 

68 

24 

67 

22 

92 

19 

51 

21 

41 

16 

43 

46 

17 

40 

26 

51 

1914 

•  •  •  • 

130 

22 

70 

24 

60 

20 

107 

21 

57 

23 

50 

20 

23 

24 

13 

30 

10 

19 

1915 

•  •  •  • 

128 

21 

74 

25 

54 

18 

89 

18 

55 

22 

34 

13 

39 

41 

19 

44 

20 

38 

1916 

•  •  •  • 

107 

18 

62 

21 

45 

14 

90 

18 

51 

20 

39 

15 

17 

18 

11 

25 

6 

11 

1917 

•  •  •  • 

92 

15 

53 

18 

39 

12 

72 

14 

41 

16 

31 

12 

20 

20 

12 

27 

8 

15 

1918 

•  •  •  • 

73 

12 

48 

16 

25 

8 

50 

10 

36 

14 

14 

5 

23 

23 

12 

26 

11 

20 

1919 

•  •  •  • 

60 

8 

36 

10 

24 

7 

50 

8 

28 

9 

22 

7 

10 

10 

8 

17 

2 

4 

1920 

•  •  •  • 

35 

5 

19 

5 

16 

4 

23 

4 

13 

4 

10 

3 

12 

11 

6 

11 

6 

11 

Considering  first  the  total  population,  it  will  be  noted  that  beginning  with 
the  second  year  of  life  with  a  rate  of  10,  from  the  second  to  the  fifth  year  the 
mortality  is  doubled,  from  the  fifth  to  the  tenth  year  the  rate  was  26,  and  from 
the  tenth  to  the  twentieth  year  40.  The  highest  mortality  fell  in  the  third  decade 
of  life  with  a  rate  of  56.  During  the  fourth,  fifth,  and  sixth  decades,  the  rates 
fell  by  rather  even  steps,  and  the  sixth  decade  of  life  was  marked  by  a  mor¬ 
tality  rate  of  13.  During  the  seventh  decade  the  rate  was  more  than  double 
that  of  the  sixth,  but  for  the  eighth  decade  it  dropped  to  19.  The  rates  for 


FEBRILE  DISEASES 


261 


total  whites  varied  little  from  those  for  the  total  population,  except  that  they 
were  lower  between  the  fifth  and  ninth  years.  The  rates  for  the  negroes  were 
uniformly  higher  than  those  for  whites  in  nearly  all  age-groups.  In  regard 
to  the  whites,  the  rates  for  females  were  higher  than  those  for  males  below 
the  tenth  year  and  between  the  tenth  and  nineteenth  years.  In  the  fourth 
decade,  the  male  rate  was  more  than  three  times  as  high  as  that  for  females, 
and  in  the  fifth  decade  it  was  double  the  female.  In  the  sixth  decade  the  female 
rate  was  higher.  Above  the  fifty-ninth  year  the  mortality  was  considerably 
higher  in  males  than  in  females.  Among  negroes,  under  the  tenth  year  the 
rates  were  higher  for  females,  but  between  the  tenth  and  twenty-ninth  years 
this  was  reversed.  In  the  fourth,  fifth,  and  seventh  decades  the  rate  for  females 


Table  27. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from 
typhoid  fever,  according  to  age,  color,  and  sex,  for  1910. 


D  =  death.  R  =  rate. 


Total. 

White. 

Colored. 

Age  period. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

Under  1  year . 

Between  1  and  2  years 

1 

10 

1 

12 

1 

23 

2  to  4  years . 

6 

19 

5 

18 

1 

7 

4 

29 

1 

24 

•  •  • 

•  •  • 

1 

47 

5  to  9  years . 

13 

26 

8 

19 

4 

18 

4 

19 

5 

78 

2 

65 

3 

89 

Under  10  years . 

20 

20 

14 

16 

6 

13 

8 

18 

6 

46 

2 

32 

4 

59 

10  to  19  years . 

41 

40 

33 

37 

14 

33 

19 

41 

8 

58 

5 

85 

3 

38 

20  to  29  years . 

63 

56 

51 

55 

26 

58 

25 

52 

12 

58 

8 

88 

4 

35 

30  to  39  years . 

40 

45 

32 

44 

24 

67 

8 

21 

8 

51 

3 

39 

5 

61 

40  to  49  years . 

21 

31 

18 

31 

12 

44 

6 

20 

3 

26 

1 

18 

2 

35 

50  to  59  years . 

6 

13 

5 

13 

2 

11 

3 

15 

1 

16 

1 

34 

•  •  • 

•  •  • 

60  to  68  years . 

8 

32 

7 

32 

5 

51 

2 

17 

1 

35 

•  •  • 

•  •  • 

1 

64 

70  to  79  years . 

2 

19 

2 

21 

1 

25 

1 

18 

80  years  and  over.... 

. 

Total  . 

201 

36 

162 

34 

90 

39 

72 

29 

39 

46 

20 

51 

19 

42 

was  much  higher  than  for  males,  but  in  the  sixth  decade  the  males  had  the 
advantage  of  a  lower  rate. 

It  was  not  until  after  the  beginning  of  the  decline  of  typhoid  fever  in  Balti¬ 
more  that  in  the  annual  reports  of  the  health  department  a  gleam  of  interest 
in  the  disease  on  the  part  of  the  authorities  can  be  discovered.  In  1875,  Com¬ 
missioner  Stuart  attributed  its  prevalence  to  sewer-gas  entering  houses  from 
imperfectly  trapped  cesspools.  By  1885,  though  still  clinging  to  this  theory 
and  basing  his  administrative  acts  chiefly  upon  it,  he  started  routine  chemical 
examinations  of  the  waters  of  the  wells  and  springs,  and  in  a  few  years  had 
condemned  many  of  these.  He  also  about  this  time  began  to  question  the 
safety  of  the  general  water-supply.  By  1890  it  was  well  recognized  that  the 
disease  was  more  prevalent  in  the  newly  annexed  territory,  with  its  water- 
supply  derived  almost  entirely  from  wells,  that  many  of  the  cases  in  the  rest 
of  the  city  contracted  the  disease  without  the  city,  and  that  large  numbers  of 


262  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

non-residents  suffering  with  the  disease  were  brought  into  the  city  for  treat¬ 
ment.  Commissioner  McShane  established  sanitary  inspection  of  the  Lake 
Roland  water-supply  in  1892,  and  4-  years  later  extended  it  to  the  Gunpowder 
watershed.  Basing  his  opinion  upon  reports  of  his  inspectors,  he  declared  in 
1896  that  the  general  water-supply  was  seriously  polluted  from  privies  on  these 
sheds.  In  1895  a  small  outbreak  was  traced  to  a  certain  milk-supply.  Case 
reporting,  established  by  law  in  1894,  had  reached  some  degree  of  complete¬ 
ness  by  1900.  The  first  study  of  typhoid  fever  was  undertaken  by  Dr.  C. 
Hampson  Jones  in  1899.  During  the  next  decade  he  pointed  out  that  the 
disease  was  rather  evenly  distributed  throughout  the  city,  and  that,  though 
milk  epidemics,  infection  from  polluted  wells,  contact  with  previous  cases  in 
households,  infection  out  of  the  city,  and  spread  of  the  disease  by  flies  all 
played  a  part,  the  great  bulk  of  the  cases  were  infected  from  the  city  water- 
supply.  By  1910,  thanks  to  the  epidemiological  inquiries  of  Dr.  Jones  and 
the  investigations  of  Dr.  Stokes,  city  bacteriologist,  and  of  Dr.  W.  W. 
Ford  (43),  of  the  department  of  pathology  and  bacteriology  of  the  Johns 
Hopkins  University,  it  was  generally  recognized  that  the  general  water-supply 
was  the  chief  means  by  which  typhoid  fever  was  spread  in  Baltimore. 

With  the  aid  of  further  and  more  exact  data  than  had  hitherto  been  avail¬ 
able,  the  writer  (59),  inquired  into  the  mode  of  infection  of  the  cases  reported 
from  1916  to  1919,  inclusive.  Hot  only  had  the  general  sanitary  conditions 
materially  changed  since  the  date  of  Dr.  Jones’s  studies,  but  in  some  ways 
they  were  constantly  improving  during  the  4  years  under  consideration.  The 
general  results  of  the  investigation,  together  with  those  of  Assistant  Commis¬ 
sioner  of  Health  Dr.  J.  F.  Hogan,  in  1920,  are  given  in  table  28.  The  relatively 
high  proportion  of  cases  certainly,  probably,  and  possibly  infected  without 
the  city  is  striking.  Most  of  those  of  the  former  division  acquired  the  disease 
in  rural  Maryland,  but  a  considerable  proportion  were  infected  in  other  States, 
notably  Virginia,  Pennsylvania,  Hew  Jersey,  and  Hew  York.  In  some  cases 
the  disease  was  acquired  as  far  away  as  Maine.  In  1916,  14  cases  were  received 
from  foreign  ships.  The  percentage  of  infections  attributed  to  recent  cases 
in  households  and  institutions  in  1918  and  1919  are  probably  not  far  from 
the  usual  occurrence  in  average  years,  for  it  would  appear  from  Dr.  Jones’s 
figures  for  1904  to  1907,  inclusive,  based  upon  less  accurate  histories,  from 
7  to  9  per  cent  of  the  cases  could  be  classed  under  this  category.  In  the 
material  for  1918,  1919,  and  1920,  many  of  these  secondary  cases  occurred  in 
hospitals  among  patients  admitted  for  other  affections,  sometimes  surgical, 
who  were  assigned  beds  next  to  those  of  typhoid  patients  and  were  attended 
by  the  same  nurse.  The  secondary  cases  developing  in  homes  were  usually  in 
the  immediate  attendants  of  the  patient.  It  is  probable  that  the  77  cases  traced 
to  milk  (infected  from  actual  cases  or  from  proven  carriers)  in  1916-1917 
were  far  short  of  actual  occurrence.  These  cases  all  occurred  in  definite  out¬ 
breaks. 

The  absence  of  recognized  milk  outbreaks  in  the  last  3  years  coincides  with 
the  improvement  in  the  supervision  of  the  milk-supply.  The  category  ascribed 
to  proven  carriers  in  households  is  included  among  the  group  of  certainly 
explained,  because  the  evidence  was  so  unusually  strong  in  each  instance  as 
to  amount  to  almost  to  a  certainty.  Ho  cases  were  attributed  to  infection 
from  springs,  wells,  and  streams,  except  where  there  was  definite  information 


FEBRILE  DISEASES 


263 


that  they  were  polluted  from  the  discharges  of  typhoid  patients.  From  one 
of  the  wells  to  which  several  cases  were  attributed,  B.  typhosus  was  isolated. 
Thirteen  of  the  15  cases  ascribed  to  this  mode  of  infection  in  1920  occurred  as  a 
sudden  outbreak  among  workers  in  a  large  office  building  in  which  a  tank  for 
flushing  closets  wras  supplied  with  water  from  a  sewer  pipe  draining  the  over¬ 
flow  from  the  long-since  abandoned  Calvert  Street  city  spring.  By  a  cross- 
connection  within  the  building  the  water  from  this  tank  mixed  with  that  from 
the  city  water-supply.  Analysis  of  water  from  both  sources  showed  a  high 


Table  28. — Modes  and  sources  of  infection  of  typhoid  fever,  from  1916  to  1920,  inclusive. 


1916 

1917 

1918 

1919 

1929 

Cases. 

Per  cent, 
of  cases. 

Cases. 

Per  cent. 

of  cases. 

Cases. 

Per  cent. 

of  cases. 

Cases. 

Per  cent. 

of  cases. 

Cases. 

Per  cent. 

of  cases. 

Certainly  explained. 

Outside  of  city . 

125 

16 

142 

26 

53 

18 

58 

16 

104 

39 

Contact  with  recent  cases  in  same  house- 

hold  or  institution . 

? 

9 

21 

4 

39 

13 

42 

12 

16 

4 

Milk  epidemics  in  which  source  of  infec- 

tion  was  demonstrated . 

34 

4 

43 

8 

Springs,  wells,  and  streams  within  city. 

4 

1 

24 

7 

15 

6 

Proven  carriers  in  households  or  insti- 

tutions . 

14 

2 

2 

•  •  • 

5 

2 

2 

1 

1 

•  •  • 

Laboratory  infections . 

1 

2 

1 

Total  . 

177 

23 

208 

38 

98 

32 

128 

36 

130 

49 

Probably  explained. 

Outside  of  city . 

» 

9 

9 

9 

16 

5 

32 

9 

12 

4 

Pemote  cases  in  households,  carrier  not 

proven  . 

9 

13 

2 

22 

7 

27 

8 

6 

2 

Cases  in  neighborhood . 

9 

9 

• 

9 

9 

9 

9 

7 

2 

3 

1 

Self-infection  . 

4 

1 

4 

1 

Total  . 

17 

3 

42 

14 

66 

18 

21 

8 

Possibly  explained. 

Outside  of  city . 

? 

9 

9 

9 

20 

7 

15 

4 

•  •  • 

•  •  • 

Total  explained  . 

177 

23 

225 

41 

160 

53 

209 

58 

151 

57 

Total  unexplained  . 

597 

77 

319 

59 

142 

47 

149 

42 

116 

43 

Total  cases . 

774 

100 

544 

100 

302 

100 

358 

100 

267 

100 

Leaders  in  columns  denote  absence  of  occurrence.  Question  marks  in  columns  denote 
absence  of  information. 


degree  of  pollution.  The  outbreak  subsided  after  severance  of  connection 
between  the  two  water-supplies.  In  the  one  instance  of  stream  infection  in¬ 
cluded,  the  stream  was  known  to  be  polluted  with  sewage  from  houses  harbor¬ 
ing  typhoid  fever.  Of  20  children  who,  while  on  a  picnic,  drank  from  this 
stream,  10  developed  fever  within  3  weeks.  The  3  laboratory  infections 
occurred  among  medical  students  who  unintentionally  sucked  into  their  mouths 
through  pipettes  bouillon  cultures  of  B.  typhosus. 

It  will  be  noted  that  the  proportion  of  cases  in  which  the  mode  of  infection 
was  ascertained  with  certainty,  during  the  5  years,  averaged  35.6  per  cent. 


264  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

Among  the  categories  in  which  the  mode  of  infection  was  ascertained  with 
probability,  two  deserve  some  comment.  Of  the  8  cases  included  under  self- 
infection,  all  the  persons  affected  had  had  the  disease  before.  As  they  were 
not  in  association  with  active  cases,  it  is  not  improbable  that  they  were  chronic 
carriers  who  became  infected  from  themselves.  A  more  interesting  group  is 
formed  by  those  who  lived  in  households  with  individuals  who  had  had  typhoid 
fever  from  1  to  30  years  before.  Of  the  68  such  persons  (including  6  proven 
carriers),  who  in  1917  to  1919,  inclusive,  were  suspected  of  transmitting 
typhoid  fever  to  members  of  their  households,  66  per  cent  were  females,  and 
this  percentage  of  males  to  females  was  approximately  the  same  in  each  year. 
The  45  females  who  were  suspected  or  proven  carriers  bore  relationships  as 
follows  to  the  typhoid-fever  patients :  Mother,  24;  sisters,  12;  wives,  3 ;  grand¬ 
mothers,  2;  aunts,  1;  domestic  servants,  3.  The  23  males  in  question  held 
relationships  to  the  patients  as  follows  :  Fathers,  9 ;  brothers,  9 ;  husbands,  3 ; 
uncles,  1 ;  unrelated,  1.  Not  all  of  the  suspected  carriers  were  cultured  and 
not  all  of  the  proven  carriers  can  now  be  separated  from  the  total.  Since  of 
the  5  of  the  latter  that  can  be  identified  with  certainty  4  were  females  (grand¬ 
mother,  sister,  and  aunt)  and  only  1  was  a  male  (father),  the  proportion  as 
above  given  would  not  be  materially  changed.  As  the  proportion  both  of  the 
proven  and  suspected  carriers  in  this  list  who  had  relationships  in  the  house¬ 
holds  most  likely  to  be  favorable  for  infecting  food  is  strikingly  high,  and  as 
for  none  of  the  cases,  whom  they  were  suspected  of  infecting,  were  any  other 
likely  sources  of  infection  traceable,  it  is  not  improbable  that  the  explanation 
is  valid. 

It  was  not  until  1900  that  case  reporting  was  complete  enough  to  yield 
morbidity  rates  worthy  of  serious  consideration.  It  is  possible  that  between 
1900  and  1915  the  errors  arising  from  failure  to  report  cases  were  largely 
offset  by  the  practice  of  including,  without  careful  investigation  of  the  subse¬ 
quent  histories,  all  suspected  cases  from  whom  blood  specimens  submitted  by 
attending  physicians  to  the  bacteriological  laboratory  gave  positive  agglutina¬ 
tion  reactions  with  B.  typhosus.  With  the  restricted  personnel,  it  was  not 
possible  to  follow  each  case  in  detail  and  to  clear  the  records  of  cases  reported 
on  evidently  mistaken  diagnosis. 

Before  1917,  cases  among  non-residents  from  rural  Maryland  were  included 
among  the  Baltimore  cases;  from  this  date  they  were  not  so  included,  but 
through  the  State  Board  of  Health  were  officially  transferred  to  the  lists  of  the 
counties  of  origin.  Some  cases  among  residents,  who,  after  contracting  the 
disease  in  the  counties,  were  brought  to  the  city,  also  fell  into  this  category. 
Cases  in  non-residents  from  other  States,  including  the  not  inconsiderable 
number  of  cases  removed  from  ships,  and  in  residents  who  contracted  the 
disease  in  other  States,  have  always  been  included  in  the  official  lists  of  Balti¬ 
more  cases.  With  fuller  histories  and  more  intensive  oversight  of  cases  than 
had  hitherto  been  practicable,  it  was  possible  after  1915  to  secure  more  accurate 
morbidity  data.  Therefore,  for  the  5-year  period  1916-1920,  it  may  be  said 
that  the  number  of  reported  cases  of  typhoid  fever  included  in  the  official  lists 
represents  with  a  fair  degree  of  certainty  the  actual  occurrence  of  cases  which 
under  the  regulations  should  be  so  listed.  These  figures  do  not,  however,  repre¬ 
sent  the  true  morbidity  of  local  origin,  for  in  these  5  years,  on  an  average,  25 
per  cent  of  the  cases  were  certainly  infected  without  the  city.  Taking  the 


FEBRILE  DISEASES 


265 


figures  as  they  stand,  the  course  of  morbidity  (table  29),  though  irregular,  rose, 
on  the  whole,  between  1900  and  1910.  During  this  period  the  rates  rose  from 
172  to  330,  or  nearly  doubled.  For  the  first  5  years  (from  1900  to  1904)  the 
curves  of  the  morbidity  and  mortality  rates  rose  and  fell  together.  During 
the  next  2  years  the  former  rose  and  the  latter  fell.  In  1907  the  two  rates 
rose  together,  but  in  1908,  while  the  morbidity  rate  remained  stationary,  the 


Table  29. — Morbidity  rate,  per  100,000  living  inhabitants,  and  the  percentage  of  case 

fatality  for  typhoid  fever,  from  1900  to  1919,  inclusive. 

C  =  cases.  R  =  rate. 


Year. 

Morbidity. 

Deaths. 

Per  cent, 
case  fa¬ 
tality. 

Year. 

Morbidity. 

Deaths.  j 

Per  cent. 

case  fa¬ 

tality. 

Year. 

Morbidity. 

Deaths. 

Per  cent. 

case  fa¬ 

tality. 

C 

R 

C 

R 

C 

R 

1900. . 

871 

172 

189 

22 

1908. . 

1426 

255 

180 

13 

1916.. 

776 

128 

107 

14 

1901. . 

792 

154 

141 

18 

1909. . 

1069 

189 

136 

13 

1917.. 

544 

89 

92 

17 

1902. . 

1086 

209 

220 

20 

1910. . 

1891 

330 

235 

12 

1918.. 

302 

49 

73 

24 

1903.. 

768 

146 

189 

25 

1911. . 

1201 

208 

154 

13 

1919. . 

359 

50 

60 

17 

1904. . 

916 

172 

199 

22 

1912. . 

1083 

185 

136 

13 

1920. . 

267 

36 

35 

13 

1905.. 

1019 

188 

197 

19 

1913. . 

1163 

197 

135 

12 

1906. . 

1215 

222 

183 

15 

1914.. 

757 

127 

130 

17 

Aver. . 

946 

168 

150 

16 

1907.. 

1417 

256 

230 

16 

1915. . 

949 

158 

128 

13 

mortality  rate  fell.  They  rose  simultaneously  to  a  peak  in  1910.  In  all  except 
3  of  the  11  years  the  curves  for  morbidity  and  mortality  rose  and  fell  together. 
In  the  remaining  10  years  of  the  period  the  morbidity  rates  fell  from  330  to 
36,  a  decrease  of  89  per  cent.  The  fall  was  not  continuous,  however,  for  in 
1913,  1915,  and  1919  there  were  reactions,  that  in  1915  being  considerable. 


Table  30. — Rate  of  morbidity,  per  100,000  living  in¬ 
habitants,  for  typhoid  fever  by  color  and  sex  for 
1918  and  1919. 


Year. 

Total. 

White. 

Colored. 

Total. 

Male. 

Fern. 

Total. 

Male. 

Fem. 

1918  . 

46 

47 

61 

34 

39 

29 

48 

1919  . 

44 

46 

51 

41 

36 

41 

25 

Average  . . . 

45 

46 

56 

37 

37 

35 

36 

The  slight  reaction  in  1919  was  associated  with  the  annexation  of  that  year, 
when  the  rate  in  the  annexed  territory  was  much  higher  than  in  the  old  city. 

The  rates  for  whites  and  negroes  and  for  males  and  females,  data  for  which 
are  available  only  for  1918  and  1919,  are  given  in  table  30.  If  the  figures  for 
these  two  years  may  be  taken  as  representative,  the  incidence  of  the  disease  is 
greater  in  the  white  race  than  in  the  colored,  greatest  in  white  males,  and 
greater  in  white  females  than  in  either  colored  males  or  females. 


266  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

As  the  value  of  case-fatality  rates  is  so  intimately  dependent  upon  the 
accuracy  of  morbidity  and  mortality  figures,  it  is  necessary  in  considering  them 
to  bear  in  mind  the  explanations  already  given  of  these.  Particularly  impor¬ 
tant  is  it  to  recall  that  while  deaths  of  all  non-residents  have  been  continuously 
recorded  in  the  city  tables  of  mortality  since  1916,  the  cases  among  non¬ 
residents  of  rural  Maryland  brought  to  Baltimore  have  been  excluded  from 
the  morbidity  lists.  Therefore,  for  the  five  years  between  1916  and  1920,  the 
case-fatality  rates  are  not  directly  comparable  with  those  of  previous  years. 
In  table  29  the  case-fatality  rates  in  percentages  are  given  from  1900  to  1920. 
In  this  period  they  fluctuate  rather  widely,  between  25  per  cent,  the  highest, 
and  12  per  cent,  the  lowest.  In  11  of  the  21  years  they  were  over  15  per  cent; 
the  lowest  rate,  12  per  cent,  was  recorded  in  two  years,  rates  of  13  per  cent,  in 
six  years,  and  of  14  and  15  per  cent  in  1  year.  With  the  exception  of  1918, 
when  in  October  a  number  of  individuals  with  typhoid  fever  died  with  influenza, 
rates  of  18  per  cent  or  over  occurred  only  during  the  first  6  years  of  this 


Table  31. — Case-fatality  rates  for  typhoid  fever,  according  to 
color  and  sex,  for  the  old  wards  of  Baltimore,  for  1919. 


Mortality. 

Morbidity. 

Percentage 

case 

fatality. 

Total  males  . 

27 

159 

17 

Total  females . 

17 

134 

13 

Total  white  . 

35 

259 

14 

White  males  . 

20 

139 

14 

White  females  . 

15 

120 

13 

Total  colored  . 

9 

34 

26 

Colored  males  . 

7 

20 

35 

Colored  females  . 

2 

14 

14 

Total  . 

44 

293 

15 

period.  It  will  be  noted  that  the  6  years,  1908  through  1913,  stand  out  as  an 
unbroken  period  of  exceptionally  low  rates.  A  rise  in  the  rates  to  17  per  cent 
in  1914  was  followed  by  a  fall  to  13  per  cent  and  14  per  cent  in  1915  and 
1916,  respectively.  High  rates  in  the  next  2  years  were  succeeded  by  a  return 
to  13  per  cent  in  1920.  However,  when  the  rates  from  1917  to  1920  are 
adjusted  to  the  basis  of  previous  years  by  the  addition  to  the  divisors  (i.  e.,  the 
reported  cases)  of  those  cases  from  rural  Maryland  which  were  transferred  to 
their  places  of  origin,  or,  what  amounts  to  the  same  thing,  by  the  subtraction 
from  the  dividends  of  the  deaths  occurring  among  them,  the  rates  are  13  per 
cent,  18  per  cent,  15  per  cent,  and  13  per  cent  instead  of  the  higher  official 
figures  given  in  the  table.  It  would  appear,  therefore,  that  if  case  reporting  be 
considered  as  fairly  accurate  since  1906,  the  normal  range  of  case  fatality  in 
Baltimore  varies  from  12  per  cent  to  18  per  cent,  with  an  average  of  14  per  cent. 

Accurate  data  for  determining  the  influence  of  sex  and  color  upon  the 
fatality  rates  of  typhoid  fever  are  limited  to  1919.  These  are  analyzed  in 
table  31.  Owing  to  the  smallness  of  the  figures  for  some  categories  and  the  lack 
of  correction  for  age,  some  of  the  percentages  are  perhaps  subject  to  con- 


FEBRILE  DISEASES 


267 


siderable  probable  error.  Taken  at  their  face  value,  the  risk  rate  of  dying 
of  clinically  recognized  typhoid  fever  was  twice  as  great  for  colored  as  for 
white,  somewhat  greater  for  white  males  than  for  white  females,  over  twice 
as  great  for  colored  males  than  for  colored  females,  and  a  fourth  greater  for 
total  males  than  for  total  females. 

Whereas  it  would  appear  that  the  greatest  incidence  of  typhoid  fever  in 
Baltimore  has  been  in  the  summer  and  autumn,  in  many  years  between  1856 
and  1881  the  number  of  deaths  in  the  winter  months,  December,  January, 
and  February,  equaled  or  even  exceeded  that  for  the  warm  months.  Since  1881 
the  bulk  of  the  deaths  have  fallen  in  the  summer  and  autumn.  Since  case 
reporting  was  instituted  the  cases  have  shown  the  same  seasonal  distribution. 
The  four  years  1915-1919  (table  32)  may  fairly  illustrate  the  average  seasonal 
distribution  of  deaths.  The  deaths  lag  about  one  month  behind  the  reported 

Table  32. — Number  of  deaths  by  months  and  monthly  annual  mortality  rate,  per 
100,000  living  inhabitants,  from  typhoid  fever,  from  1915  to  1919,  inclusive. 


D  =  death.  R  =  rate. 


1915 

1916 

1917 

1918 

1919 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

Jan . 

11 

22 

8 

16 

7 

13 

2 

4 

4 

7 

Feb . 

7 

15 

4 

9 

3 

6 

3 

6 

5 

9 

Mar.  . . . 

5 

10 

2 

4 

4 

8 

2 

4 

4 

7 

Apr . 

6 

12 

4 

8 

8 

16 

7 

14 

•  •  • 

•  •  • 

May  .... 

4 

8 

3 

6 

7 

13 

3 

6 

8 

13 

June  ... 

9 

18 

7 

14 

3 

6 

2 

4 

4 

7 

July  .... 

14 

27 

14 

27 

6 

12 

5 

10 

3 

5 

Aug.  . . . 

14 

27 

11 

21 

13 

25 

14 

27 

8 

13 

Sept.  . . . 

22 

45 

20 

40 

13 

26 

11 

22 

9 

15 

Oct . 

12 

23 

21 

41 

14 

27 

17 

32 

5 

8 

Nov . 

17 

34 

10 

20 

9 

18 

1 

2 

6 

10 

Dec . 

7 

14 

3 

6 

5 

10 

6 

11 

4 

7 

Total  . 

128 

21 

107 

18 

92 

15 

73 

12 

60 

8 

cases,  but  follow  the  same  general  course.  For  cases,  with  February  usually  as 
the  month  of  lowest  incidence,  there  is  a  gradual  progression  of  the  disease  until 
July,  when  there  is  a  rapid  rise  culminating  in  a  peak  usually  about  the  middle 
of  September,  or  more  rarely  the  last  of  August  or  even  early  in  October. 
The  decline  is  usually  very  abrupt  during  the  first  month  after  the  peak,  and 
then  more  gradual  to  the  end  of  the  cycle. 

Administrative  measures  directed  particularly  to  the  control  of  typhoid 
fever  developed  very  gradually.  As  early  as  1888,  wells  to  which  certain  cases 
were  traced  were  closed,  and  a  few  years  later  from  time  to  time  several  local 
epidemics  traced  to  milk  were  controlled  by  shutting  off  the  contaminated 
milk-supplies.  It  was  not  until  1912,  however,  that  measures  were  taken 
routinely  to  prevent  the  entrance  into  the  city  of  milk  from  farms  harboring 
cases  of  typhoid  fever  and  to  guard  milk  within  the  city  from  infection  from 
cases  on  the  premises  of  milk  handlers  and  of  the  general  public.  Investiga¬ 
tions  conducted  in  1916  and  1917  showed  that  in  spite  of  these  barriers 
18 


268  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

numbers  of  small  milk  epidemics  occurred.  Only  since  1916  have  cultures 
been  made  of  suspected  carriers  on  dairy  farms,  among  milk  and  other  food 
handlers,  and  in  households  and  institutions,  and  control  exercised  over  proven 
carriers.  It  was  not  until  1916  that  printed  instructions  giving  in  detail  the 
precautionary  measures  to  be  taken  to  prevent  the  spread  of  typhoid  fever 
were  delivered  to  households  and  institutions  with  patients  with  this  disease, 
and  attempts  made  to  enforce  them  through  the  health  wardens  and  nurses. 
Since  this  date  special  efforts  have  been  made  to  have  patients  from  crowded 
households  removed  to  hospitals.  Since  its  introduction  the  health  department 
has  systematically  urged  the  use  of  protective  inoculation,  and  has  required  it 
of  attendants  in  hospitals  receiving  typhoid  fever  patients.  The  response  on 
the  part  of  the  general  public  has  not  been  encouraging,  and  the  decrease  in 
the  incidence  of  the  disease  of  late  years  can  not  be  credited  in  any  large  degree 
to  this  method  of  protection.  Whereas  no  exact  quantitative  valuation  can  be 
set  upon  them,  there  is  a  large  body  of  evidence  supporting  the  inference  that 
restrictive  measures  imposed  on  the  acts  of  persons  by  the  health  department 
and  by  physicians  have  very  materially  decreased  the  spread  of  typhoid  fever 
in  the  community  during  the  last  decade. 

SUMMARY. 

When  the  curve  for  the  annual  rates  for  the  acute  intestinal  diseases  as  a 
whole  is  viewed  for  the  entire  period,  several  distinct  waves  of  mortality  stand 
out  clearly.  (Table  19,  graph  8.)  The  first,  beginning  at  some  unknown  time 
previous  to  1812  and  characterized  by  rates  fluctuating  between  297  in  1814 
and  664  in  1818,  ended  in  1827  with  the  comparatively  low  rate  of  181.  The 
second  wave,  starting  in  1828,  reached  its  peak  in  1832  with  the  remarkably 
high  rate  of  1,412  and  receded  very  brokenly  to  its  low  point  in  1839  with  a 
rate  of  162.  But  for  the  influence  of  the  cholera  epidemics  of  1832  and  1834, 
the  rates  in  these  years  would  have  stood  at  486  and  340  instead  of  1,412  and 
412,  respectively.  However,  as  it  is  certain  that  a  considerable  number  of  deaths 
from  cholera  were  attributed  to  cholera  infantum  and  to  cholera  morbus  and 
cramp  colic,  it  is  evident  that  cholera  exercised  an  influence  upon  the  high 
rates  for  these  two  years  even  greater  than  is  shown  by  the  official  figures.  It  is 
equally  clear,  however,  that  before  the  advent  of  cholera  the  rates  were  tending 
to  higher  levels  during  the  first  few  years  of  this  period.  The  third  wave,  not 
only  short  but  relatively  low,  reached  its  peak  in  1842  with  a  rate  of  252. 
By  1845  it  had  subsided  to  167.  The  fourth  wave,  characterized  by  excessively 
high  rates,  began  in  1846  and  ended  in  1865.  The  rise  in  the  rates  to  a  peak 
of  659  in  1854  was  gradual,  but  somewhat  irregular.  The  fall  to  the  end  of 
the  wave,  with  a  rate  of  342  was  almost  uninterrupted.  This  wave  was  asso¬ 
ciated  with  a  rise  in  the  rates  for  every  one  of  the  separate  causes,  including 
cholera.  The  latter  disease,  though  hidden  under  other  rubrics,  contributed 
in  no  small  degree  to  the  high  rates  of  1849  and  1854  and  perhaps  other  years. 
Coincident  with  the  return  of  cholera  in  1866,  a  fifth  wave  began,  reached  a 
peak  in  1874  with  a  rate  of  528,  and  subsided  in  1878,  when  the  rate  stood  at 
264.  A  sixth  wave,  beginning  in  1879  and  running  an  irregular  course,  attained 
its  peak  in  1890  with  a  rate  of  390  and  subsided  in  1903,  when  the  rate  fell 
to  162.  After  an  interval  of  64  years,  the  rate  now  stood  at  the  same  level  as 


FEBRILE  DISEASES 


269 


in  1839.  The  seventh  and  last  wave,  which  began  in  1904,  is  still  in  progress. 
It  is  characterized  by  relatively  low  and,  on  the  whole,  constantly  descending 
rates,  which  during  the  last  5  years  have  shown  a  tendency  to  stabilize  around 
a  comparatively  low  level.  During  the  whole  period,  with  the  exception  of 
a  few  years,  the  slope  of  the  curve  has  been  determined  chiefly  by  cholera 
infantum,  which,  but  for  cholera  and  for  diarrhoea  in  occasional  years,  has 
been  the  chief  contributor. 

The  course  of  mortality  for  the  group  as  a  whole  in  relation  to  that  for  its 
various  members  may  be  studied  conveniently  in  the  curves  for  the  rates  as 
averaged  for  5-year  periods.  (Table  20,  graph  9.)  For  more  accurate  com-, 
parison,  the  rates  for  cholera  infantum  and  diarrhoea  are  given  in  combina¬ 
tion  as  well  as  separately.  It  will  be  observed  that  beginning  with  a  rate  of 
406  for  the  4  years  ending  in  1815,  the  whole  rate  stood  at  462  in  1816-1820, 
413  in.  1821-1825,  and  242  in  1826-1830.  The  averaged  rates  for  each  of  the 
separate  rubrics,  cholera  infantum,  diarrhoea  (and  for  these  two  combined), 
and  typhoid  fever,  all  rose  and  fell  with  the  total  rate.  For  the  5-year  period 
ending  in  1835,  this  favorable  course  was  reversed  and  the  total  rate  rose  to  517. 
This  change  was  associated  writh  a  stationary  state  for  the  rate  for  diarrhoea 
and  a  fall  in  that  for  typhoid  fever  and  a  relatively  slight  rise  in  that  for 
dysentery.  The  rate  for  cholera  infantum  rose  sharply.  The  determining  cause 
for  this  notable  rise  in  the  total  rate  was  the  entry  of  a  new  element,  Asiatic 
cholera,  in  1832  and  1834.  But  for  these  events  the  elevation  of  the  total  rate 
for  this  5-year  period  would  have  been  relatively  slight,  i.  e.,  only  75,  when 
the  averaged  rates  of  200  due  to  cholera  are  subtracted  from  the  total  rates. 
Concurrent  with  the  declines  in  rates  for  each  separate  rubric,  except  the 
negligible  typhoid  rate,  there  was  a  sharp  fall  to  202  in  the  total  rate  for  the 
5  years  ending  in  1840.  In  1845  the  combined  rate  stood  practically  unchanged 
at  208.  Since  1825,  therefore,  it  had  declined  by  approximately  50  per  cent. 
This  striking  change  was  due  to  declines  in  the  rates  for  cholera  infantum, 
diarrhoea,  and  dysentery,  and  of  the  absence  of  cholera  between  1835  and  1840. 
In  other  words,  this  result  was  brought  about  by  declines  during  the  20-year 
period,  1826-1845,  in  the  rates  for  the  indigenous  members  of  the  group. 
The  total  rate  was  not  destined  again  to  attain  so  low  a  level  until  1905. 

That  this  fall  in  the  rates  was  not  due  to  failure  to  register  deaths  is 
proven  by  the  fact  that  Joynes,  Wynne,  and  Frick,  who  made  careful  statistical 
studies  of  the  Baltimore  material  of  this  time,  accepted  the  official  figures  of 
the  total  number  of  deaths  as  substantially  correct  and  by  the  evidence  that 
the  decline  in  the  rates  for  this  particular  group  of  diseases  coincided  with  a 
similar  decline  in  the  death-rates  for  all  causes.  In  the  5-year  period  ending 
in  1850,  the  whole  situation  changed.  Due  to  corresponding  changes  in  the 
rates  for  cholera  infantum,  diarrhoea,  dysentery,  and  typhoid  fever,  the  total 
rate  rose  to  357.  By  1855  it  had  surpassed  any  previous  high  level  and  stood 
at  534.  This  time,  in  addition  to  rises  for  the  three  usually  responsible  rubrics, 
typhoid  fever,  hitherto  unimportant,  achieved  a  rate  of  58,  and  cholera, 
present  in  1854  in  a  form  much  more  fatal  than  was  officially  recognized,  added 
materially  to  the  toll  of  death  from  these  diseases.  For  the  5  years  ending  in 
1860,  as  the  result  of  the  absence  of  cholera  and  decline  in  the  rates  for  diar¬ 
rhoea,  dysentery,  and  typhoid  fever,  the  total  rate  fell  to  475.  Cholera  infantum 
rose,  however,  to  300,  the  highest  level  yet  recorded.  A  further  decline  in 


270  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

the  total  rate  to  373  in  1861-1865  was  owing  mainly  to  a  sharp  drop  in  the 
rates  for  cholera  infantum  and  for  dysentery ;  typhoid  fever  rose  conspicuously. 
This  improvement  in  the  total  rate  was  but  temporary,  for,  turning  upward, 
it  registered  436  in  1866-1870.  This  change,  while  influenced  to  some  degree 
by  a  small  outbreak  of  cholera  in  1866,  was  brought  about  chiefly  by  increases 
in  the  rates  for  cholera  infantum,  diarrhoea,  dysentery,  and  typhoid  fever. 
The  rate  for  the  latter  had  now  reached  the  highest  point  recorded  in  its 
history.  With  slight  declines  in  other  rubrics  and  a  sharp  rise  in  cholera 
infantum,  the  total  rate  stood  at  457  in  1871-1875.  With  recessions  for  every 
rubric,  the  total  rates  declined  to  346  in  1876-1880  and  316  in  1881-1885. 

During  the  40  years  between  1846  and  1885  there  was,  then,  a  very  conspicu¬ 
ous  change  in  the  curve  for  the  acute  intestinal  diseases,  resulting  in  a  wave 
with  two  sharp  crests,  the  first  in  1860  and  the  second  in  1875.  This  change 
was  brought  about  during  the  first  crest  in  part  by  two  relatively  moderate 
visitations  of  cholera  (1849  and  1854),  but  mainly  by  unusual  fatality  from 
dysentery,  cholera  infantum,  diarrhoea,  and  typhoid  fever,  and  during  the 
second  crest  by  high  rates  for  all  the  other  members  of  the  group  save  dysentery 
and  cholera.  The  decline  in  the  total  rate  between  these  two  crests,  which 
reached  its  lowest  point  during  the  Civil  War,  was  due  to  a  fall  in  the  rates  for 
cholera  infantum  and  dysentery  and  to  the  absence  of  cholera.  Cholera  played 
no  conspicuous  role  after  1866.  The  influence  of  the  decline  in  the  rates 
for  cholera  infantum,  dysentery,  and  typhoid  fever  upon  the  total  rate  after 
1875  is  very  evident.  The  ascent  in  the  total  rate  to  359  during  the  5-year 
period  ending  in  1886-1890  was  due  to  sharp  rises  in  the  rates  for  dysentery 
and  diarrhoea.  Cholera  infantum  remained  stationary,  and  typhoid  fever  con¬ 
tinued  its  gradual  decline.  During  the  25  years  between  1891  and  1915  the 
total  rate  fell  uninterruptedly  from  359  to  131,  but  the  rate  of  decline  was 
much  less  acute  during  the  first  three  than  during  the  last  two  quinquennia  of 
the  period.  After  1900,  dysentery  ceased  to  be  a  factor  of  importance  and 
typhoid  fever  continued  to  fall.  But  for  an  upward  turn  between  1901  and 
1905,  the  decline  in  the  rate  for  cholera  infantum  was  continuous.  Diarrhoea, 
after  rising  slightly  between  1891  and  1895,  had  fallen  to  a  relatively  low 
level  by  1905.  The  rates  for  these  two  rubrics  taken  together  fell  continuously 
between  1891  and  1915.  There  was  no  fall  in  the  total  rate  for  the  5  years 
ending  in  1920.  The  considerable  fall  for  typhoid  fever  was  counterbalanced 
by  slight  reactions  in  the  rates  for  the  other  rubrics. 

To  what  degree  may  the  courses  of  these  diseases  be  explained  by  changes  in 
environment  and  population  and  by  improvements  in  medical  care  and  admin¬ 
istrative  efforts  of  a  special  character  on  the  part  of  the  health  department  ?  In 
the  history  of  the  water-supply  it  has  been  pointed  out  that  the  drinking-water 
has  been  subject  to  pollution  from  the  earliest  times:  The  intra-urban  supply 
from  springs  and  wells,  the  main  dependence  of  the  major  part  of  the  popula¬ 
tion  until  after  1850,  must  have  been  seriously  polluted  from  the  earliest  days. 
Contamination  was  doubtless  to  some  degree  lessened  for  a  time  at  least  after 
the  enforcement  of  the  ordinances  of  1817  and  1820  requiring  the  abandonment 
of  privies  in  certain  localities  and  the  water-tight  construction  of  cesspools 
near  springs  and  wells.  That  these  measures  were  not  thoroughly  protective 
seems  certain,  for  the  evidence  at  hand  indicates  that  cholera  was  commonly  if 
not  invariably  spread  by  the  internal  water-supply,  and  that  the  cesspools  were 


FEBRILE  DISEASES 


271 


constantly  overflowing.  With  the  rapid  increase  in  the  population,  particularly 
between  1800  and  1830  and  between  1846  and  1855,  the  pollution  of  the  springs 
and  w7ells  must  have  grown  rapidly  worse.  Many  were  closed  by  administrative 
authority  between  1870  and  1900,  and  after  the  latter  date  but  few  remained. 

The  external  water-supply,  available  to  only  a  small  proportion  of  the  popu¬ 
lation  when  introduced  in  1808,  served  perhaps  one-third  of  the  people  by  1825 
and  at  most  one-half  by  1850.  It  is  improbable  that  it  was  seriously  polluted 
before  1845  or  1850.  From  this  date  until  1881,  when  the  Gunpowder  supply 
became  the  chief  source,  the  pollution  must  have  been  very  grave.  This  latter 
supply,  which  became  progressively  the  subject  of  contamination  from  the 
increase  in  the  village  and  farming  population  on  its  tributaries,  was  improved 
to  a  considerable  degree  by  storage  in  the  numerous  reservoirs  in  the  city. 
Until  1915  water  from  the  heavily  polluted  Jones  Falls-Lake  Roland  water¬ 
shed  was  mixed  with  it.  By  1895  both  water-sheds  were  so  contaminated  that 
sanitary  inspectors  were  employed  to  guard  them.  There  is  abundant  evidence 
that  between  1845  and  1911,  wrhen  chlorinization  was  introduced,  either  part 
or  all  of  the  external  water-supply  was  subject  to  serious  pollution  with  excreta 
of  man  and  domestic  animals.  Chlorinization  since  1911  and  filtration  and 
chlorinization,  together  with  the  abandonment  of  the  Lake  Roland  supply 
since  1915  and  the  partial  abatement  of  nuisances  on  the  Gunpowder  watershed, 
have  greatly  reduced  but  not  entirely  offset  the  dangers  of  pollution  of  the 
drinking-water.  It  is  probable  that  since  1919,  at  least,  it  has  been  at  most 
times  free  from  micro-organisms  responsible  for  the  acute  intestinal  affections. 
Highly  important  in  connection  with  the  pollution  of  the  external  water-supply 
is  the  circumstance  that  it  has  never  been  subject  to  contamination  from  the 
intestinal  discharges  of  large  communities  of  human  beings.  The  complete 
absence  of  large  towns  and  of  cities  on  the  water-sheds  has  doubtless  meant 
much  in  this  regard.  With  the  exception  of  Towson,  a  town  of  1,000  inhabitants 
on  the  Lake  Roland  watershed,  the  pollution  of  the  external  water-supply  with 
human  excreta  has  been  limited  to  that  derived  from  a  relatively  thinly  settled 
countryside  dotted  with  occasional  villages.  While  the  pollution  from  these 
sources  has  been  far  from  negligible  and  has  increased  markedly  in  recent  years, 
it  has  never  been  comparable  in  degree  with  that  obtaining  in  connection  with 
the  watersheds  of  many  American  and  foreign  cities.  Had  there  been  large 
urban  communities  discharging  sewage  into  the  sources  of  the  Jones  Falls  and 
in  later  years  into  those  of  the  Lake  Roland  and  Gunpowder  watersheds,  Balti¬ 
more  could  hardly  have  escaped  so  lightly  from  cholera,  and  the  rates  from 
typhoid  fever,  dysentery,  and  diarrhoea  must  have  been  notably  higher  than 
those  experienced.  From  the  consideration  of  nuisances  connected  with  imper¬ 
fect  drainage,  privies,  cesspools,  lack  of  proper  paving,  and  defective  methods 
of  removal  and  disposal  of  garbage  and  manure,  it  is  evident  that,  until  very 
recent  years,  conditions  were  most  favorable  for  the  spread  of  this  group  of 
diseases  by  pollution  of  the  intraurban  water-supply  and  of  milk  and  by  flies 
and  other  insects.  With  the  gradual  abandonment  of  wells  and  springs  within 
the  city  between  1870  and  1900,  the  danger  from  privies  and  cesspools  was 
practically  limited  to  the  possibilities  of  spread  of  infection  by  flies,  and  great 
as  were  the  esthetic  benefits  of  the  new  sewage  system,  its  actual  sanitary 
influence  when  brought  into  service  between  1912  and  1918  was  much  less 
marked  than  would  have  been  the  case  at  an  earlier  date.  As  a  result  of  the 


272  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

marked  general  improvement  in  municipal  housekeeping  during  the  last  20 
years,  and  particularly  since  1910,  the  danger  from  fly  infection  has  greatly 
decreased. 

In  the  discussions  of  the  milk-supply  it  has  been  made  clear  that,  before 
administrative  efforts  at  its  control  were  begun  in  1894,  a  large  proportion  of 
the  milk  was  deficient  in  quality  and  exposed  constantly  to  numerous  opportuni¬ 
ties  for  contamination.  Until  the  ice-supply  was  increased  and  cheapened 
through  improvements  in  transportation  and  storage,  and  artificial  ice  became 
available,  much  of  the  milk  was  either  not  refrigerated  at  all  or,  at  least,  very 
defectively.  The  administrative  reforms  begun  in  1894  showed  results  almost 
immediately  in  the  great  improved  food  value  of  milk  and  in  the  cutting  down 
to  some  degree  of  the  possibilities  of  contamination  from  impure  water  and 
from  flies.  In  spite  of  laws  and  of  persistent  and  well-directed  administrative 
efforts,  as  late  as  1917  the  general  sanitary  conditions  under  which  the  bulk  of 
the  milk  was  handled  were  deplorable  and  the  opportunities  for  contamination 
were  endless.  Until  this  date  milk-borne  outbreaks  of  typhoid  fever  were  com¬ 
mon,  and  with  the  notable  exception  of  the  Walker-Gordon  Laboratory  and  of 
a  few  dealers  who  in  recent  years  pasteurized  with  care,  the  milk-supply  was 
doubtless  often  infected  with  the  causal  agents  of  dysentery  and  diarrhoea  as 
well.  Whatever  dangers  may  be  incident  to  high  bacterial  content  were  almost 
constant  attributes  of  the  bulk  of  the  milk  until  the  fall  of  1918. 

Of  other  foods  likely  to  be  infected  outside  the  city,  the  fresh  vegetables 
commonly  eaten  raw,  such  as  lettuce,  celery,  radishes,  cabbage  for  slaw,  and  the 
like,  and  fruits  like  strawberries,  were  perhaps  not  infrequently  contaminated 
from  city  night-soil  so  generally  used  as  fertilizer  by  neighboring  farmers. 
Danger  from  this  source  persisted  until  1917. 

While  the  great  oyster-beds  of  the  lower  Chesapeake  have  always  been  reason¬ 
ably  safe  from  sewage  contamination,  opportunity  for  the  spread  of  typhoid 
fever  and  perhaps  of  dysentery  and  diarrhoea  by  infected  oysters  has  existed 
from  the  earliest  times  until  recent  years.  In  earlier  years  productive  oyster- 
beds  were  near  enough  to  the  city  to  be  contaminated  from  the  sewage-polluted 
waters  of  the  city  streams  and  the  basin,  but  a  more  serious  menace  in  this 
regard  was  due  to  the  custom,  proscribed  only  in  the  last  few  years,  of  fattening 
oysters  in  polluted  waters  off  the  towns  below  the  city. 

The  imperfect  methods  of  collection  and  disposal  of  garbage,  slaughter  and 
packing  house  refuse,  night-soil,  and  stable  manure  which  obtained  until  the 
last  few  years  resulted  in  the  presence  in  houses,  cellars,  yards,  courts,  alleys, 
streets,  streams,  and  the  basin  of  an  abundance  of  organic  matter  to  attract 
and  to  feed  the  swarms  of  flies  bred  in  the  numerous  stables  within  the  city. 

When  the  growth-rates  of  the  population  expressed  in  percentages  of  increase 
and  the  averaged  death-rates  from  this  group  of  diseases  are  compared  (table 
33)  over  decennial  periods,  a  very  definite  correlation  is  evident.  The  very  high 
death-rate  for  the  decennium  ending  in  1820  followed  growth  increases  of  76 
per  cent  between  1801  and  1810  and  of  35  per  cent  between  1811  and  1820. 
A  decided  decline  in  the  death-rate  by  1830  coincided  with  a  continued  fall 
in  the  rate  of  population  increase.  The  practically  stationary  state  of  the  rate 
of  population  increase  between  1831  and  1840  was  accompanied  by  a  relatively 
slight  increase  in  the  death-rate  in  1840  and  a  fall  in  1850  to  the  lowest  level 
recorded  until  1900.  But  for  the  occurrence  of  epidemic  cholera  in  1832  and 


FEBRILE  DISEASES 


273 


1834,  the  death-rate  for  the  period  ending  in  1840  would  have  shown  a  decided 
drop.  It  is  clear,  then,  that,  so  far  as  the  indigenous  diseases  of  this  group  are 
concerned,  in  a  period  of  diminishing  immigration  following  a  period  of  very 
high  immigration-rates,  the  death-rates  fell  significantly  from  a  very  high  to 
a  relatively  low  level.  But  between  1841  and  1850  the  rate  of  population 
increase  jumped  to  65  per  cent  and  was  reflected  in  1860  by  an  increase  in 
the  death-rate  by  80  per  cent  over  1850.  With  the  decline  in  the  percentages 
of  population  increase  to  26  for  the  decennia  ending  in  1860  and  in  1870  and 
24  for  that  ending  in  1880,  the  death-rates  fell  by  20  per  cent  in  1870,  remained 
stationary  in  the  next  decade,  and  declined  considerably  between  1881  and  1890 
in  the  face  of  a  slight  increase  in  the  rate  of  population  growth  during  this 
last  period.  From  1891  to  1910  the  rates  for  mortality  and  for  population 
growth  fell  steadily  together.  With  a  slight  rise  in  the  rate  of  population 
growth  between  1911  and  1920,  the  fall  in  the  death-rate  was  less  acute  than 
in  the  previous  decennium.  The  close  correspondence  between  these  fluctuations 


Table  33. — Percentage  of  population  increase  between  census  counts  contrasted  with 
average  rates  of  deaths,  per  100,000  living  inhabitants,  by  10-year  periods  from 
acute  intestinal  diseases,  from  1800  to  1920,  inclusive. 


Periods. 

Per  cent,  of 
population  in¬ 
crease  between 
census  counts. 

Average  rates 
of  death  from 
acute  intestinal 
diseases  by 
10-year  periods. 

Periods. 

Per  cent,  of 
population  in¬ 
crease  between 
census  counts. 

Average  rates 
of  death  from 
acuteintestinal 
diseases  by 
10-year  periods. 

1801-1810 _ 

76 

•  •  • 

1861-1870 _ 

26 

404* 

1811-1820 _ 

35 

437 

1871-1880 _ 

24 

402 

1821-1830 _ 

29 

328 

1881-1890 _ 

31 

338 

1831-1840.... 

27 

360* 

1891-1900 _ 

17 

278 

1841-1850 _ 

65 

280 

1901-1910 _ 

10 

182 

1851-1860 _ 

26 

505* 

1911-1920 _ 

14 

131 

*  Periods  during  which  there  occurred  epidemics  of  cholera. 


in  rates  of  population  growth  and  the  death-rates  from  this  group  of  diseases 
finds  a  ready  explanation  in  the  recorded  history  of  the  general  sanitation  of 
the  city.  The  periods  of  rapid  growth  were  marked  by  overcrowding  and  by  a 
multiplication  of  nuisances  of  all  types,  but  especially  of  those  connected  with 
the  pollution  first  of  the  internal  and  then  of  the  external  water-supply.  A 
considerable  period  elapsed  before  the  ill  effects  of  the  great  migration  1846  to 
1855  could  be  even  partially  adjusted  by  construction  and  administration,  and 
the  sanitary  habits  of  the  newcomers,  many  of  whom  had  been  accustomed  to 
live  in  cellars  or  hovels,  had  approached  the  level  of  those  of  the  older  citizen¬ 
ship.  Any  considerable  degree  of  slackening  of  immigration  would,  on  the  other 
hand,  exercise  a  salutary  effect. 

As  foreign  immigrants  have  higher  birth-rates  than  the  native-born,  and  as 
high  birth-rates  result  in  a  larger  proportion  in  the  population  of  those  most 
susceptible  to  acute  intestinal  affections,  it  is  to  be  supposed  that  high  immigra¬ 
tion-rates,  such  as  occurred  between  1846  and  1855,  would  be  followed  by  a 
period  of  high  death-rates  from  these  diseases,  and  notably  from  cholera  infan¬ 
tum.  As  according  to  the  figures  of  Frick  in  1850,  the  mortality-rates  for 
cholera  infantum  were  more  than  double  and  those  for  dysentery  were  more 


274  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

than  four  times  greater  in  whites  than  in  negroes,  and,  as  in  1919,  typhoid  fever 
was  more  than  twice  as  fatal  for  negroes  as  for  whites,  it  may  be  concluded 
that  a  large  proportion  of  negroes  has  exerted  a  favorable  effect  upon  the 
death-rates  for  the  former  and  an  unfavorbale  effect  upon  those  for  the  latter. 
There  can  be  little  doubt  that  the  fall  in  the  rates  since  1880  have  been  due  to 
some  degree  to  the  habit  of  a  large  proportion  of  the  foreign  immigrant  women 
entering  after  that  date  to  nurse  their  babies.  It  is  certain  that  typhoid  fever 
and  dysentery  were  introduced  on  a  large  scale  by  foreign  immigrants  in  the 
middle  of  the  last  century.  Indeed,  the  epidemic  outbreak  of  dysentery  at 
that  time  is  probably  to  be  laid  at  their  door.  There  is  reason  to  suppose  that 
these  diseases  spread  to  the  civil  population  from  the  large  number  of  cases 
brought  to  the  large  military  hospitals  established  in  the  city  during  the 
Civil  War.  It  has  been  established  that  not  only  have  many  cases  of  typhoid 
fever  been  brought  into  the  city  for  treatment  from  rural  Maryland  and  by 
foreign  and  coastwise  shipping,  but  that  many  citizens  have  acquired  both 
typhoid  fever  and  dysentery  while  on  visits  elsewhere.  It  has  been  shown  that 
the  health  department  has  never  undertaken  the  sanitary  control  of  persons 
with  dysentery,  diarrhoea,  and  cholera  infantum,  and  that  measures  of  this 
nature  were  first  applied  to  cholera  in  1866  and  to  typhoid  fever  in  1916. 
While  a  favorable  outcome  in  dysentery  and  diarrhoea  have  undoubtedly  been 
determined  by  medical  treatment  since  the  earliest  days,  it  is  doubtful  if 
medical  care  influenced  the  death-rate  from  cholera,  or,  if  before  1885  or  1890, 
the  fate  of  individuals  with  cholera  infantum  or  typhoid  fever  was  on  the 
whole  very  materially  affected  by  the  ministrations  of  the  average  physician 
or  hospital.  Beyond  question,  since  1890  most  of  the  decline  in  the  death-rate 
from  cholera  infantum  and  much  of  that  from  typhoid  fever,  and  to  a  con¬ 
siderable  degree  the  decrease  in  the  incidence  of  both,  are  to  be  ascribed  to 
the  actions  of  medical  men. 


Chapter  XI. — Typically  Contactive  Diseases. 


1.  Acute  exanthematous  diseases:  Small-pox;  Cowpox;  Chicken-pox; 

Scarlet  fever;  Measles;  Influenza.  (Tables  34  to  59,  graphs  11  to  16.) 

2.  Acute  inflammatory  affections  of  the  respiratory  tract:  Whooping- 
cough;  Diphtheria;  Pneumonia.  (Tables  60  to  77,  graphs  17  to  20.) 

3.  Tuberculosis.  (Tables  78  to  90,  graphs  21  to  26.) 

THE  EXANTHEMATOUS  DISEASES,  OR  THOSE  ACUTE 
FEBRILE  COMMUNICABLE  DISEASES  CHARACTER¬ 
IZED  BY  ERUPTIONS  OF  THE  SKIN  AND 
CERTAIN  MUCOUS  MEMBRANES. 

The  diseases  of  this  class  which  have  been  recognized  in  the  statistical  nos¬ 
ology  of  the  Baltimore  health  department  are  variola  or  small-pox,  vaccinia  or 
cow-pox,  varicella  or  chicken-pox,  morbilli  or  measles,  scarlatina  or  scarlet 
fever,  and  influenza.  The  members  of  this  group  of  diseases  have  in  common 
many  characteristics.  These  concern  especially  the  seats  and  characters  of  their 
principal  lesions,  their  mode  of  spread,  their  seasonal  distribution,  their 
reaction  upon  the  community,  their  age  incidence,  and  to  a  certain  degree  their 
causation  and  their  immunity  relations.  They  are  all  marked  by  cutaneous 
eruptions  symmetrically  distributed,  and  which  for  three  (small-pox,  chicken- 
pox,  and  vaccinia,  especially  when  generalized)  are  so  alike  in  appearance  and 
anatomical  changes  that  in  many  respects  they  can  be  differentiated  only  after 
close  study.  The  early  eruption  of  small-pox,  and  especially  in  the  severe  cases 
in  which  death  occurs  early  in  the  disease,  closely  resembles  those  of  measles 
and  scarlet  fever,  and  the  latter  two  were  until  comparatively  recent  times 
confused  with  each  other  and  with  small-pox. 

The  cutaneous  eruptions  of  measles,  scarlet  fever,  and  influenza,  though 
widely  different  from  the  more  marked  inflammatory  lesions  of  small-pox  and 
chicken-pox,  are  among  themselves  of  the  same  general  character,  and,  except 
for  certain  peculiarities  of  surface  distribution  and  arrangement,  often  so 
alike  as  to  give  rise  to  confusion  in  diagnosis. 

In  all  of  them  which  occur  under  natural  conditions  in  man,  there  is  con¬ 
junctivitis,  usually  slight  but  sometimes  severe,  which  may  extend  to  the  inner 
structures  of  the  eye.  It  is  a  well-established  fact  that  any  of  them  except 
vaccinia  and  chicken-pox  may  occur  without  recognized  cutaneous  lesions. 
It  is  quite  true  that  the  cutaneous  eruption  of  influenza  is  often  absent  and  is 
not  clearly  characteristic,  as  are  the  cutaneous  lesions  of  the  other  affections 
of  this  group;  but  it  is  undeniably  true  that  such  an  eruption  is  commonly 
found  in  the  victims  of  the  disease  if  looked  for  carefully. 

In  the  whole  group  (vaccinia  excepted)  certain  lesions  of  the  mouth,  tonsils, 
pharynx,  larynx,  and  bronchi,  varying  from  discrete  or  diffuse  areas  of  conges¬ 
tion  to  definite  inflammatory  processes,  are  commonly  present.  When  diffuse, 
these  lesions  are  alike;  only  when  discrete  are  they  apt  to  present  characters 

275 


276 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


pathognomonic  of  any  particular  member  of  the  group.  While  victims  of  cer¬ 
tain  of  them  are  not  particularly  prone  to  develop  inflammatory  lesions  of  the 
middle  ear,  accessory  sinuses,  tonsils,  pharynx,  bronchi,  and  lungs — often  more 
serious  than  the  primary  affections — such  lesions  not  infrequently  occur  in  per¬ 
sons  affected  by  the  others. 

In  their  mode  of  spread,  chiefly  if  not  invariably  by  personal  contact  (except 
vaccinia),  these  diseases  are  strictly  comparable.  And  again,  excepting  vac¬ 
cinia,,  their  reaction  to  warm  weather  is  in  general  the  same.  With  few  excep¬ 
tions  they  all  flourish  only  in  the  colder  seasons,  tending  almost  invariably 
when  endemic  to  die  down  during  warm  weather,  to  spring  up  in  the  autumn 
and  gather  force,  to  reach  their  zenith  in  the  winter  or  spring,  and  gradually 
to  subside  with  the  development  of  warm  weather.  As  a  rule,  also,  when  they 
occur  as  epidemics,  this  general  rule  is  adhered  to. 

All  of  them,  except  chicken-pox  and  vaccinia,  have,  as  will  appear  later, 
repeatedly  entered  Baltimore  as  epidemics,  more  or  less  widespread  and  fatal, 
and  have  after  a  period  of  from  one  to  several  years,  completely  died  out  with¬ 
out  attacking,  in  recognizable  form,  all  persons  of  susceptible  age  and  not 
previously  affected.  After  repeated  experiences  of  this  character,  small-pox, 
measles,  scarlet  fever,  and  influenza  have  become  endemically  established. 
In  their  known  immunity  reactions  these  diseases  bear  close  resemblances. 
As  a  rule,  in  each  disease,  with  the  probable  exception  of  influenza,  one  attack 
confers  either  at  most  complete  and  permanent  immunity,  or,  at  least,  an  im¬ 
munity  for  a  prolonged  period  with  assurance  of  lightness  of  succeeding  attacks. 
It  is  characteristic  of  them  all,  though  in  varying  degree,  that  during  an  attack 
the  resistance  of  the  body  as  a  whole,  and  of  the  respiratory  tract  in  particular, 
with  the  exception  of  vaccinia,  is  lowered  to  infection  with  pyogenic  micro¬ 
organisms,  especially  pneumococcus,  streptococus,  and  staphylococcus.  Two  of 
them,  small-pox  and  vaccinia,  are  interchangeably  protective,  and  the  latter 
in  practice  is  available  as  a  substitute  for  the  former.  These  diseases,  when 
once  established  in  large  communities,  have  defied  such  attempts  at  interference 
with  their  spread  as  household  quarantine  and  disinfection.  Household  and 
general  sanitation,  nuisance  control  (with  the  single  exception  of  prevention 
of  the  spread  of  scarlet  fever  by  means  of  milk),  and  riches  and  poverty,  are 
all  alike  without  discernible  influence  upon  their  course.  Small-pox,  restricted 
doubtless  to  some  degree  by  vaccination  attacks  incompletely  organized,  worked 
its  way  effectively  for  many  years. 

All  of  these  diseases  share  in  common  a  proneness  to  attack  the  age  group 
1  to  20  or  30  years. 

The  illusive  virus  of  each  1  has  resisted  discovery  under  repeated  attacks 
upon  its  identity  with  the  use  of  all  the  resources  of  the  microscopic  and 
cultural  methods  of  modern  microbiology.  Ho  one  has  been  able  to  demonstrate, 
in  relation  with  the  characteristic  lesions  of  any  of  these  affections,  parasites 
satisfactorily  explaining  them.  In  those  members  of  this  group  which  have 
proved  capable  of  transmission  to  laboratory  animals,  the  viruses  have  been 
shown  to  pass  fine  filters. 

The  specific  virus  of  each  member  of  the  group  appears  to  be  able  to  resist  dry¬ 
ing.  Ho  convincing  evidence  exists  that  the  virus  of  any  of  them  requires  an  in¬ 
termediate  host  either  for  development,  preservation,  or  spread.  The  characters, 


1  See  footnote,  p.  44. 


FEBRILE  DISEASES 


277 


seats,  and  distributions  of  the  essential  lesions  of  all  these  diseases,  as  they 
occur  under  natural  conditions,  indicate  that  their  viruses  are  spread  through¬ 
out  the  body  by  means  of  the  blood-vessels  and  have  their  primary  and,  in  some 
of  them,  their  principal  effect  upon  the  blood-capillaries.  Thus  they  all  present 
the  typical  indications  of  general  rather  than  local  affections.  As  if  to  em¬ 
phasize  these  characteristics  held  in  common  by  each  of  these  diseases,  with 
the  possible  exception  of  vaccinia,  in  examples  of  unusual  severity,  hemorrhages 
into  the  skin,  mucous  membranes,  and  even  into  certain  organs  are  usual. 

Points  of  difference,  on  the  other  hand,  are  not  lacking.  Vaccinia,  under 
natural  conditions,  in  the  present  age  at  least,  is  not  a  peculiar  disease  of  man. 
Occurring,  with  few  exceptions,  only  when  transferred  by  inoculation,  it  is  not 
capable  of  propagating  itself  in  this  species  indefinitely  by  contact  or  whatso¬ 
ever  other  means  usual  for  diseases  of  this  group.  Again,  the  incubation  periods 
of  members  of  the  group  vary  not  only  among  the  two  divisions  least  alike, 
but  among  those  most  alike  in  their  superficial  lesions. 

In  their  finer  details,  the  characteristic  lesions  of  the  diseases  most  alike 
show  differences  which  may  be  regarded  as  specific.  It  is  unnecessary  to  indi¬ 
cate  other  points  of  difference  which  will  be  evident  enough  to  the  initiated. 
Enough  has  been  brought  forward  to  indicate  that  in  the  present  discussion 
it  is  not  sought  to  prove  identity,  but  to  establish  similarity  among  the  members 
of  this  in  many  ways  peculiar  group  of  diseases. 

SMALL-POX. 

There  are  no  definite  records  of  the  prevalence  and  fatality  of  small-pox 
in  Baltimore  before  1811,  though,  judging  from  the  accounts  of  its  prevalence 
in  Maryland  in  1743,  1755,  1756,  1760,  1762,  1765,  1767,  and  1771,  and  from 
the  activity  of  Dr.  Henry  Stevenson  as  an  inoculator,  it  must  have  frequently 
entered  and  spread  in  the  town.  In  connection  with  the  history  of  vaccination, 
it  is  recorded  that  small-pox  was  prevalent  in  Baltimore  in  1800,  1801,  and 
1810.  The  considerable  epidemic  of  1811-1812,  with  death-rates  of  153  and 
183  respectively,  was  the  first  one  of  consequence  in  the  nineteenth  century. 
Except  for  a  few  cases  in  1810,  when  the  disease  was  said  to  have  been  “  soon 
extinguished  by  vaccination,”  small-pox  had  been  absent  several  years.  This 
epidemic  subsided  as  suddenly  as  it  arose,  and  the  disease  did  not  reappear, 
at  least  in  fatal  form,  until  1816,  when  there  were  2  deaths.  Except  for  1 
death  in  1818  and  1819,  fatal  small-pox  was  not  again  recorded  until  1821. 
It  is  worthy  of  note  that,  after  this  severe  epidemic,  the  disease  practically 
died  out  for  10  years  (table  34,  graph  11).  The  few  deaths  recorded  between 
1813  and  1821  were  apparently  associated  with  very  limited  outbreaks,  or  with 
isolated  imported  cases.  It  is  certain  that  the  city  was  free  from  recognized 
small-pox  in  1820. 

The  epidemic  of  1821-1822,  with  death-rates  of  35  in  the  former  and  194 
in  the  latter  year,  which  was  as  sudden  and  unheralded  as  the  one  of  10  years 
before,  was  traced  to  the  importation  of  cases  of  small-pox  on  the  ship  Pallas. 
The  disease  died  down  in  1823,  but  there  were  a  few  deaths  each  year  until 
1830,  except  in  1829,  with  rate  varying  from  2  to  9.  Again  the  former  experi¬ 
ence  was  repeated,  though  not  exactly,  for  in  some  years,  at  least,  after  the 
subsidence  of  the  epidemic,  the  disease  was  perhaps  endemic. 


278  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


Table  34. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from  small¬ 
pox,  vaccinia,  varicella,  scarlet  fever,  measles,  influenza,  and  total  acute  exanthematous 
diseases  excluding  vaccinia,  and  percentage  of  the  total  deaths,  from  1812  to  1920,  inclusive. 


Acute  exanthematous  diseases. 


Year. 

Small-pox. 

Vaccinia. 

Vari¬ 

cella. 

Scarlet 

fever. 

Measles. 

In¬ 

fluenza. 

Total 

(excluding 

vaccinia). 

Per  cent, 
of  total 
deaths 
(excluding 
vaccinia). 

D 

R 

Vacci¬ 

nations- 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1811 

60 

153 

60 

153 

•  • 

1812 

•  •  •  • 

75 

183 

75 

183 

6 

1813 

33 

77 

33 

77 

3 

1814 

1 

2 

1 

2 

1815 

8 

17 

25 

53 

33 

71 

2 

1816 

2 

4 

7 

14 

9 

18 

1 

1817 

. 

•  • 

1818 

1 

2 

2 

4 

3 

6 

1819 

1 

2 

116 

209 

117 

211 

5 

1820 

4 

7 

4 

7 

1821 

21 

35 

1 

2 

3 

5 

2 

3 

27 

45 

1 

1822 

122 

194 

4 

6 

126 

201 

6 

1823 

2 

3 

1 

2 

175 

268 

178 

272 

9 

1824 

2 

3 

14 

21 

16 

24 

1 

1825 

3 

4 

3 

4 

9 

13 

15 

21 

1 

1826 

5 

7 

3 

4 

8 

11 

1827 

•  •  •  • 

7 

9 

4019 

5251 

1 

1 

8 

10 

i 

1828 

•  •  •  • 

2 

3 

2 

3 

#  # 

1829 

•  •  •  • 

•  •  •  • 

•  •  • 

2762 

3474 

•  •  • 

•  •  • 

1 

1 

46 

56 

47 

57 

3 

1830 

2 

2 

147 

172 

7 

8 

156 

182 

8 

1831 

25 

28 

3398 

3824 

161 

181 

23 

26 

11 

12 

220 

248 

10 

1832 

79 

86 

673 

730 

1 

1 

16 

17 

2 

2 

114 

124 

212 

230 

6 

1833 

32 

34 

141 

148 

12 

13 

185 

194 

8 

1834 

71 

72 

1068 

1080 

1 

1 

143 

145 

77 

78 

9 

9 

300 

303 

12 

1835 

3 

3 

13 

13 

5 

5 

13 

13 

34 

33 

2 

1836 

•  •  •  • 

1 

1 

130 

123 

... 

•  •  • 

30 

28 

1 

1 

•  •  • 

•  •  • 

32 

30 

«  1 

1837 

•  •  •  • 

53 

48 

2753 

2512 

4 

4 

134 

122 

141 

129 

•  •  • 

•  •  • 

332 

303 

13 

1838 

•  •  •  • 

72 

64 

1000 

882 

2 

2 

141 

124 

4 

4 

•  •  • 

•  •  • 

219 

193 

9 

1839 

•  •  •  • 

2 

2 

2213 

1889 

1 

1 

112 

96 

57 

49 

•  •  • 

•  •  • 

172 

147 

8 

1840 

11 

9 

3 

2 

71 

59 

32 

26 

117 

97 

6 

1841 

1 

1 

1 

1 

74 

59 

6 

5 

82 

66 

4 

1842 

1 

1 

2655 

2058 

•  •  • 

27 

21 

103 

80 

•  •  • 

•  •  • 

131 

102 

5 

1843 

•  •  •  • 

•  •  •  • 

•  •  • 

2254 

1694 

•  •  • 

•  •  • 

56 

42 

4 

3 

9 

7 

69 

52 

3 

1844 

370 

270 

1 

1 

371 

270 

14 

1845 

.... 

110 

78 

3367 

2379 

•  •  • 

•  •  • 

288 

204 

20 

14 

1 

1 

419 

296 

14 

1846 

•  •  •  • 

115 

79 

3707 

2542 

1 

1 

132 

91 

114 

78 

•  •  • 

•  •  • 

362 

248 

12 

1847 

•  •  •  • 

2 

1 

1805 

1201 

1 

1 

166 

110 

7 

5 

•  •  • 

•  •  • 

176 

117 

5 

1848 

•  •  •  • 

5 

3 

1763 

1139 

•  •  • 

•  •  • 

407 

263 

74 

48 

•  •  • 

•  •  • 

486 

314 

13 

1849 

•  •  •  • 

20 

13 

2159 

1355 

1 

1 

154 

97 

31 

19 

4 

3 

210 

132 

5 

1850 

•  •  •  • 

153 

93 

1987 

1212 

3 

2 

225 

137 

7 

4 

1 

1 

389 

237 

9 

1851 

•  •  •  • 

104 

62 

3738 

2217 

3 

2 

234 

139 

21 

12 

•  •  • 

362 

215 

9 

1852 

•  •  •  • 

66 

38 

1948 

1123 

■  •  • 

•  •  • 

232 

134 

314 

181 

•  •  • 

612 

353 

12 

1853 

•  •  •  • 

9 

5 

1604 

900 

•  •  • 

•  •  • 

362 

203 

16 

9 

•  •  • 

387 

217 

8 

1854 

•  •  •  • 

26 

14 

2513 

1371 

1 

1 

234 

128 

99 

54 

•  •  • 

360 

196 

7 

1855 

•  •  •  • 

50 

27 

3910 

2077 

6 

3 

131 

70 

14 

7 

•  •  • 

201 

107 

4 

1856 

•  •  •  • 

8 

4 

2236 

1156 

3 

2 

222 

115 

8 

4 

•  •  • 

241 

125 

5 

1857 

•  •  •  • 

91 

46 

4121 

2076 

2 

1 

353 

178 

205 

103 

# 

651 

328 

13 

1858 

310 

152 

8576 

4209 

•  •  • 

•  •  • 

535 

263 

39 

19 

•  •  • 

884 

434 

16 

1859 

•  •  •  • 

1 

•  •  • 

1770 

847 

•  •  • 

•  •  • 

301 

144 

57 

27 

•  •  • 

359 

172 

8 

1860 

•  •  •  • 

•  •  •  • 

•  •  • 

2277 

1062 

•  •  • 

•  •  • 

116 

54 

109 

51 

•  •  • 

225 

105 

5 

1861 

•  •  •  • 

1 

*  •  • 

2992 

1360 

3 

1 

252 

115 

11 

5 

•  •  • 

267 

121 

6 

1862 

•  •  •  • 

34 

15 

1663 

737 

•  •  • 

•  •  • 

575 

255 

154 

68 

763 

338 

15 

1863 

•  •  •  • 

252 

109 

2862 

1238 

2 

1 

339 

147 

17 

7 

•  •  • 

610 

264 

11 

1864 

•  •  •  • 

436 

184 

6044 

2552 

4 

2 

136 

57 

143 

60 

•  •  • 

719 

304 

13 

1865 

. . . . 

18 

7 

2315 

954 

•  •  • 

. . . 

86 

35 

11 

5 

. . . 

115 

47 

2 

FEBRILE  DISEASES 


279 


Table  34. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from  small¬ 
pox,  vaccinia,  varicella,  scarlet  fever,  measles,  influenza,  etc. — Continued. 


Acute  exanthematous  diseases. 


Small-pox. 

Vaccinia. 

Vari¬ 

cella. 

Scarlet 

fever. 

Measles. 

In¬ 

fluenza. 

Total 

(excluding 

vaccinia). 

Per  cent, 
of  total 
deaths 

I) 

R 

Vacci¬ 

nations- 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

(excluding 

vaccinia). 

1866 

•  •  •  • 

13 

5 

2076 

835 

1 

•  •  • 

121 

49 

105 

42 

240 

97 

4 

1867 

•  •  •  • 

891 

350 

1 

•  •  • 

137 

54 

8 

3 

146 

57 

3 

1868 

•  •  •  • 

2216 

851 

•  •  • 

•  •  • 

127 

49 

196 

75 

323 

124 

5 

1869 

•  •  •  • 

1822 

684 

•  •  • 

-•  •  • 

171 

64 

227 

85 

398 

149 

6 

1870 

•  •  •  • 

1329 

487 

3 

1 

256 

94 

35 

13 

294 

108 

4 

1871 

•  •  •  • 

5364 

1923 

4 

1 

625 

224 

111 

40 

740 

265 

10 

1872 

•  •  •  • 

1043 

366 

50650 

17756 

4 

1 

141 

49 

161 

56 

1349 

473 

15 

1873 

•  •  •  • 

469 

161 

87739 

30084 

•  •  • 

•  •  • 

115 

39 

46 

16 

630 

216 

8 

1874 

•  •  •  • 

0000 

1136 

381 

3 

1 

234 

78 

93 

31 

330 

111 

4 

1875 

•  •  •  • 

1 

1741 

571 

•  •  • 

519 

170 

15 

5 

535 

176 

7 

1876 

•  •  •  • 

•  •  •  • 

1634 

525 

•  •  • 

562 

181 

16 

5 

578 

186 

8 

1877 

•  0  •  • 

•  •  •  • 

3397 

1068 

•  •  • 

447 

141 

151 

47 

598 

188 

8 

1878 

•  •  •  • 

1 

1457 

449 

•  •  • 

141 

43 

11 

3 

153 

47 

2 

1879 

•  •  •  • 

1 

2186 

659 

1 

367 

111 

43 

13 

1 

413 

125 

5 

1880 

•  •  •  • 

1 

8467 

2501 

000 

400 

118 

12 

4 

413 

122 

5 

1881 

11 

3 

20100 

5816 

2 

1 

215 

62 

75 

22 

1 

304 

88 

3 

1882 

551 

156 

94693 

26850 

•  •  • 

179 

51 

71 

20 

801 

227 

9 

1883 

•  •  •  • 

633 

176 

217050 

60319 

1 

334 

93 

130 

36 

1098 

305 

12 

1884 

•  •  •  • 

1 

1567 

427 

3 

1 

104 

28 

228 

62 

336 

92 

4 

1885 

•  •  •  • 

•  •  •  • 

2012 

537 

000 

68 

18 

16 

4 

84 

22 

1 

1886 

•  •  •  • 

1 

3042 

797 

000 

32 

8 

201 

53 

234 

61 

3 

1887 

•  •  •  • 

4066 

1045 

1 

36 

9 

85 

22 

122 

31 

1 

1888 

•  •  •  • 

7458 

1778 

•  •  • 

44 

10 

176 

42 

220 

52 

2 

1889 

•  •  •  • 

7411 

17  35 

•  •  • 

71 

17 

11 

3 

82 

19 

1 

1890 

•  •  •  • 

11281 

2596 

•  •  • 

42 

10 

248 

57 

17 

4 

307 

71 

3 

1891 

•  •  •  • 

10703 

2421 

3 

1 

128 

29 

16 

4 

244 

55 

391 

88 

4 

1892 

•  •  •  • 

33249 

7398 

1 

258 

57 

120 

27 

190 

42 

569 

127 

5 

1893 

•  •  •  • 

20875 

4570 

1 

36 

8 

39 

9 

62 

14 

138 

30 

•  • 

1894 

•  •  •  • 

42042 

9059 

1 

85 

18 

3 

1 

132 

28 

221 

48 

•  • 

1895 

0,00 

12990 

2755 

•  •  • 

59 

13 

68 

14 

185 

39 

312 

66 

3 

1896 

•  •  •  • 

13759 

2875 

2 

31 

6 

27 

6 

60 

13 

120 

25 

1 

1897 

•  •  •  • 

12905 

2656 

1 

53 

11 

16 

3 

88 

18 

158 

33 

2 

1898 

•  •  •  • 

11817 

2397 

•  •  • 

46 

9 

48 

10 

70 

14 

164 

33 

2 

1899 

•  •  •  • 

1 

36491 

7296 

24 

5 

5 

1 

231 

46 

261 

52 

3 

1900 

•  •  •  • 

9023 

1780 

,00 

20 

4 

24 

5 

77 

15 

121 

24 

1 

1901 

•  •  •  • 

15400 

2997 

1 

11 

2 

3 

1 

128 

25 

143 

28 

1 

1902 

•  •  •  • 

7 

1 

46412 

8913 

•  •  • 

37 

7 

41 

8 

28 

5 

113 

22 

1 

1903 

•  •  •  • 

2 

11566 

2193 

•  •  • 

84 

16 

77 

15 

92 

17 

255 

48 

3 

1904 

•  •  •  • 

4 

1 

23440 

4389 

1 

143 

27 

6 

1 

122 

23 

276 

52 

3 

1905 

•  •  •  • 

5979 

1106 

1 

33 

6 

67 

12 

91 

17 

192 

36 

2 

1906 

0  0  0  0 

9319 

1703 

4 

1 

47 

9 

14 

3 

54 

10 

119 

22 

1 

1907 

0  0  0  0 

3769 

681 

•  •  • 

15 

3 

74 

13 

105 

19 

194 

35 

2 

1908 

0  0  0  0 

5926 

1058 

■  •  • 

70 

13 

17 

3 

173 

31 

260 

46 

2 

1909 

0  0  0  0 

1277 

226 

0  0 

25 

4 

54 

10 

79 

14 

158 

28 

2 

1910 

0  0  0  0 

8161 

1426 

1 

49 

9 

19 

3 

72 

13 

141 

25 

1 

1911 

0  0  0  0 

7561 

1307 

m  0  0 

44 

8 

77 

13 

86 

15 

207 

36 

2 

1912 

0  0  0  0 

4663 

798 

1 

23 

4 

5 

1 

71 

12 

100 

17 

1 

1913 

0  0  0  0 

27424 

4648 

000 

40 

7 

118 

20 

48 

8 

206 

35 

2 

1914 

0  0  0  0 

3 

1 

15693 

2634 

6 

1 

39 

7 

6 

1 

72 

12 

126 

21 

1 

1915 

•  •  »  * 

7223 

1201 

0  0  , 

33 

5 

17 

3 

97 

16 

147 

24 

1 

1916 

0  0  0  0 

6515 

1073 

2 

30 

5 

34 

6 

129 

21 

195 

32 

2 

1917 

0  0  0  0 

8894 

1452 

000 

11 

2 

51 

8 

108 

18 

170 

28 

2 

1918 

0  0  0  0 

10230 

1656 

4 

1 

8 

1 

75 

12 

1741 

282 

1828 

296 

11 

1919 

4 

1 

30 

4 

7 

1 

406 

56 

447 

62 

4 

1920 

3 

13 

2 

49 

7 

324 

44 

389 

53 

3 

280  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


It  will  be  well  here  to  consider  very  briefly  the  character  and  extent  of  the 
protective  measures  against  small-pox  up  to  1830.  Inoculation  against  small¬ 
pox  is  said  to  have  been  practiced  in  Maryland  since  shortly  after  its  introduc¬ 
tion  into  England  in  1717.  Besides  other  well-known  inoculators  in  Maryland, 
there  was  the  widely  celebrated  Richard  Brooke,  of  Prince  George  County,  who 
devised  the  “  American  method  ”  described  in  a  tract  published  by  Benjamin 
Franklin  in  1730,  and  afterwards  widely  adopted.  Dr.  Henry  Stevenson,  one 
of  the  most  successful  inoculators,  practiced  the  art  in  Baltimore  as  early  as 
1755,  and  maintained  for  many  years  an  inoculation  hospital  in  the  suburbs 
of  Baltimore  Town.  His  charges  were  2  pistoles  (perhaps  32  shillings)  for 
inoculation  and  20  shillings  a  week  for  board  and  lodging.  It  is  probable, 

LOGO  Ff. 


- SMALLPOX. 

- varicella 

- INFLUENZA 


YEAR 

Graph  11  (from  table  34).  Annual  crude  mortality  rates  from  small-pox, 
varicella  and  influenza,  from  1812  to  1920,  inclusive. 

therefore,  that  on  account  of  the  cost  and  the  scant  hospital  accommodations 
available,  the  protection  of  inoculation  was  within  the  reach  of  only  the  very 
well-to-do.  The  procedure  was,  however,  held  in  high  esteem,  and  was  con¬ 
tinued  to  some  extent  until  abolished  by  law  in  1850. 

Vaccination  against  small-pox  was  first  practiced  in  Baltimore  in  the  summer 
of  1800,  by  Dr.  John  Crawford,  with  virus  received  from  Ring,  of  London. 
The  second  supply  of  vaccine  virus,  obtained  some  months  later  from  London, 
through  Mr.  William  Taylor,  came  into  the  hands  of  Dr.  James  Smith,  attend¬ 
ing  physician  to  the  almshouse.  On  May  1,  1801,  Dr.  Smith  vaccinated  a  girl 
of  7  years,  and  later  a  considerable  number  of  other  patients  at  the  almshouse. 
It  is  narrated  that,  though  all  of  Smith’s  cases  were  exposed  to  small-pox,  then 
prevalent,  none  contracted  the  disease.  Though  the  virus  was  freely  offered, 
no  one  could  then  be  prevailed  upon  to  use  it  generally.  In  1802,  Dr.  Smith 


FEBRILE  DISEASES 


281 


established  a  vaccine  institute,  which,  in  one  form  or  another,  he  maintained 
for  many  years.  Their  first  doubts  removed  by  the  success  of  Smith’s  experi¬ 
ments,  the  local  physicians  became  ardent  vaccinationists.  The  faculty  endorsed 
the  procedure  in  1802  and  again  in  1805.  During  the  small-pox  epidemic  of 
1812  the  members  offered  to  vaccinate  gratuitously  all  who  applied  and  to  pay 
25  cents  to  each  child  presenting  proof  of  genuine  vaccination. 

A  lottery  was  granted  in  1809  to  extend  the  work  of  the  Vaccine  Institute, 
and  in  1812  a  vaccine  society  was  organized  by  leading  citizens.  In  that  year 
the  society  was  responsible  for  994  vaccinations,  694  of  which  were  gratuitous. 
About  this  time,  too,  the  National  Vaccine  Institute  was  established  in  Balti¬ 
more  under  Dr.  Smith’s  direction. 

During  the  epidemic  year  1821,  at  the  suggestion  of  the  faculty,  a  vaccine 
physician  was  appointed  in  each  ward  to  vaccinate  the  poor,  and  this  became 
a  permanent  feature  of  the  public-health  organization  in  1824.  At  this  time, 
too,  the  health  department  became  responsible  for  having  on  hand  a  pure  and 
potent  vaccine  virus.  Up  to  1827,  administrative  efforts  to  control  small-pox 
by  vaccination  were  limited  to  furnishing  virus  freely,  providing  free  vaccina¬ 
tion  to  the  poor,  and  employing  moral  suasion  to  promote  its  general  adoption. 

In  April  of  this  year,  when  small-pox,  introduced  in  virulent  form  by 
shipping,  was  spreading  rapidly,  and  many,  particularly  among  the  free  negroes, 
refused  vaccination,  the  health  department  was  granted  power  to  vaccinate  all 
persons  in  the  neighborhood  of  cases  of  small-pox,  and,  in  a  short  time,  517 
persons  were  vaccinated  under  this  provision.  This  law  remained  the  main 
dependence  of  the  health  department  in  fighting  actual  outbreaks  of  small-pox 
until  greater  powers  were  conferred  by  the  ordinance  and  the  State  law  of  1864. 
There  is  no  record  of  the  number  of  public  vaccinations  prior  to  1827.  For 
this  year,  when  the  deaths  from  small-pox  numbered  only  9,  the  four  vaccine 
physicians  were  credited  with  performing  4,019  vaccinations,  a  rate  of  5,251 
(table  34).  For  1829  the  vaccination-rate  was  3,474.  No  record  was  made  of 
the  number  of  vaccinations  for  1828  and  1830.  There  is  little  doubt  that  the 
proportion  of  public  vaccinations  was  much  greater  after  than  before  the  con¬ 
ferring  of  greater  powers  upon  the  health  department  in  1827.  It  is  probably 
fair  to  assume  that  during  the  epidemics  of  1811-1812  and  1821-1822,  under 
the  influence  of  the  propaganda  conducted  by  the  medical  profession,  the 
vaccine  society,  and  the  health  department,  a  very  considerable  proportion  of 
the  better-to-do  and  more  intelligent  of  the  population  were  vaccinated  at 
least  once,  and  that  during  the  last  epidemic  a  considerable  number  of  the 
poorer  classes  availed  themselves  of  the  services  of  the  vaccine  physicians. 
It  is  likely  that  by  1830  a  very  considerable  proportion,  but  certainly  not  more 
than  one-half,  of  the  population  had  been  vaccinated. 

During  this  period  the  health  department  possessed  the  right  to  enforce 
isolation  of  small-pox  cases  and  contacts  in  houses  and  institutions,  to  clean 
and  disinfect  the  latter,  and  to  destroy  infected  clothing,  bedding,  and  the  like. 
But  its  personnel  and  machinery  for  exercising  its  power  were  wofully  deficient. 
Case  reporting,  except  by  tavern  and  boarding-house  keepers  and  masters  of 
vessels  in  the  harbor,  was  voluntary.  In  times  of  epidemic,  the  few  police  were 
called  upon  to  act  as  searchers  and  watchmen,  and,  though  the  vaccine  physi¬ 
cians  were  doubtless  ever  on  the  watch  for  small-pox  cases  and  must  have  been 


282  PUBLIC  HEALTH  ADMINISTRATION",  ETC.,  IN  BALTIMORE 

in  position  to  hear  of  cases  seen  by  physicians,  many  hidden  cases  among  free 
negroes  and  recent  immigrants  must  have  escaped  them. 

Practically  speaking,  there  were  no  adequate  hospital  facilities.  The  small 
hospital  building  at  Hawkins’  Point  was  distant  and  difficult  of  access.  The 
accommodations  at  the  lazaretto  were  scanty  and  not  sufficient  to  care  for 
patients  and  suspects  from  the  extensive  shipping. 

While  small-pox  was  certainly  included  in  the  list  of  “  pestilential  diseases  ” 
against  which  maritime  quarantine  applied,  time  and  again  cases  filtered 
through  the  wide  meshes  of  its  sieve.  Quarantine  by  land  was  not  attempted. 

The  conclusion  is  inevitable  that  the  course  of  small-pox  in  Baltimore  during 
the  period  under  consideration  was  not  materially  influenced  by  artificial  inter¬ 
ferences  of  the  ordinary  sort,  and  that  during  the  period  previous  to  1827  the 
natural  history  of  the  disease  could  not  have  been  very  seriously  modified  by 
vaccination. 

The  year  1831  ushered  in  a  new  phase  which  lasted  until  1866.  During  the 
period  of  36  years  in  only  four  years  were  deaths  not  recorded,  and  probably  in 
no  year  did  the  city  lack  cases.  Very  characteristic  of  this  period  was  the 
occurrence  of  numbers  of  outbreaks  or  minor  epidemic  waves  with  low  mortality 
rates  as  compared  with  the  previous  epidemics  and  extending  over  from  2  to  4 
years.  The  intervals  between  the  outbreaks  varied  from  one  to  several  years. 
It  appears  that  during  most  of  this  period  small-pox  was  endemically  estab¬ 
lished,  and  that  these  repeated  outbreaks  were  due  in  part  to  exacerbations  of 
the  indigenous  disease  and  in  part  to  new  importations. 

The  first  of  these  minor  outbreaks,  extending  over  the  4  years  1831-1834 
ran  a  somewhat  irregular  course,  with  rates  of  28,  86,  34,  and  72  for  the  several 
years.  The  rates  dropped  abruptly  to  3  in  1835  and  to  1  in  1836.  This  out¬ 
break  was,  to  some  degree  at  least,  modified  by  administrative  measures. 
A  small  hospital  for  small-pox  cases  had  been  established  within  the  city,  and 
vaccination,  with  virus  renewed  by  “  passage  ”  through  a  cow,  was  pushed. 
According  to  Dr.  Jameson’s  report,  6,000  persons  were  vaccinated  in  1831, 
though  the  official  number  credited  to  the  vaccine  physicians  was  under  4,000. 
Unfortunately,  the  figures  for  vaccination  were  not  given  in  the  reports  for 
1833  and  1835.  The  vaccination-rates  for  1832,  1834  and  1836  are  very  low. 
Dr.  Jameson  attributed  the  continued  prevalence  of  small-pox  to  the  fact  that 
many  persons  who  had  been  properly  vaccinated  in  childhood  neglected  vaccina¬ 
tion  at  puberty.  His  demand  for  general  compulsory  vaccination  was  not 
granted. 

The  second  wave,  marked  by  rates  of  48  in  1837  and  64  in  1838,  subsided 
in  1839,  and  in  two  of  the  following  four  years  no  deaths  were  recorded.  The 
vaccinations  were  recorded  too  irregularly  to  permit  judgment  in  regard  to 
their  effect  upon  the  disease  at  this  time.  There  were  flare-ups  of  the  disease 
with  moderately  high  death-rates  in  1845-1846,  1849-1852,  and  1854-1855. 
The  vaccination-rate  was  relatively  high  only  in  1845,  1846,  1851,  and  1855. 
After  1846,  a  considerable  number  of  small-pox  cases  were  sent  to  the  new 
Marine  Hospital,  and  as  the  deaths  among  these  were  not  credited  to  the  city, 
the  mortality  rates  calculated  on  the  official  figures  after  this  date  are  lower 
than  actual  experience. 

The  considerable  epidemic  of  1857-1858,  with  rates  of  46  and  152,  was 
associated  with  a  high  vaccination-rate  (4,209)  in  the  latter  year.  With  the 


FEBRILE  DISEASES 


283 


subsidence  of  this  outbreak  the  disease  lay  dormant  until  1862,  when  there 
began  a  serious  epidemic  which  lasted  over  the  Civil  War.  Death-rates  of  109 
and  184  were  attained  in  1863  and  1864.  The  vaccination-rates  were  relatively 
low — 2,552  in  1864  being  the  highest. 

During  much  if  not  most  of  this  period  the  administrative  measures  designed 
to  control  the  spread  of  the  disease  were  very  lax.  As  late  as  1857  complaint 
was  made  in  the  annual  report  that  vaccination  was  very  incomplete,  that 
unvaccinated  persons  in  the  incubative  stage  of  small-pox  moved  at  will  from 
infected  to  non -infected  districts,  and  that  convalescents  were  freed  from 
quarantine  too  early.  As  evidence  of  the  insufficiency  of  the  system  of  non- 
compulsory  vaccination  in  effect,  it  was  pointed  out  that  in  December  1857,  in 
the  midst  of  an  epidemic,  in  1,173  calls  at  houses  the  vaccinators  performed 
only  1,637  vaccinations.  The  weakness  of  the  administration’s  position  is  evi¬ 
dent  from  the  fact  that  this  number  comprised  nearly  half  the  public  vaccina¬ 
tions  performed  that  year. 

The  conferring  of  greater  powers  to  the  health  department  by  the  city 
government,  and  the  establishment  by  the  State  legislature  of  compulsory 
vaccination  of  children  before  the  end  of  the  first  year  and  the  State  vaccine 
agency,  all  in  1864,  were  reflections  of  the  severe  epidemic  of  1862-1864. 
Strangely  little  allusion  was  made  to  the  epidemic  of  the  Civil  War  period, 
Fortunately,  Charles  Frick  published,  in  1855,  data  from  which  may  be  drawn 
a  clear  picture  of  the  distribution  of  deaths  from  small-pox  by  color,  sex,  and 
age.  In  his  analysis  of  the  deaths  from  small-pox  for  the  year  1850  in  Balti¬ 
more,  Frick,  who  had  access  to  the  original  records,  found  that,  for  the  whites 
the  deaths  were  8.1  and  for  the  blacks  14.5  to  10,000  inhabitants,  or  nearly 
double  among  the  latter  race.  The  disease  was  more  fatal  to  males  than  to 
females  in  the  proportion  of  60.6  per  cent  of  the  first  to  39.4  per  cent  of  the 
latter.  The  proportion  of  the  deaths,  at  different  ages,  is  shown  in  table  35. 

Table  35. 


p.  c. 

Under  1  year .  18.0 

Between  1  and  5  years .  30.8 

Between  5  and  10  years .  7.5 

Between  10  and  20  years .  7.7 

Between  20  and  30  years .  17.0 

Between  30  and  60  years .  17.3 

Over  60  years .  1.7 


The  death-rates  specific  for  age  are  given  in  table  36. 

The  high  rates  obtaining  among  infants  and  young  children  indicates  that 
the  routine  vaccination  of  children  in  the  first  or  second  year  of  life  had  not 
yet  become  a  general  custom  in  the  community. 

After  an  absence  of  4  years,  small-pox  made  its  appearance  in  Baltimore 
in  November  1871,  following  the  importation  of  a  case  from  Philadelphia, 
where  the  disease  was  prevalent  in  severe  form.  There  were  no  deaths  registered 
in  1871,  but  in  January  and  February  1872  there  were  1  and  14  deaths  respec¬ 
tively.  Thus  by  March  there  was  well  under  way  an  epidemic  which  lasted 
until  July  1873,  and  which  proved  to  be  the  severest  in  the  city’s  history.  The 
course  of  the  disease  as  marked  by  the  monthly  annual  mortality  rates  is  well 
shown  on  table  37.  The  dip  in  the  curve  during  August,  September,  October, 
19 


284  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


and  November  1872,  may  be  ascribed  partly  to  the  well-known  influence  of 
season  and  partly  to  the  efforts  of  the  health  department,  particularly  in 
pushing  vaccination.  However  this  may  be,  after  a  very  rapid  and  steep  ascent, 
the  highest  peak  in  the  curve  was  reached  in  July  1872,  with  a  monthly  annual 
death-rate  of  1,081.  This  was  followed  by  the  abrupt  fall  to  a  relatively  low 
level  for  4  months,  which  in  turn  was  succeeded  by  a  sharp  rise,  beginning  in 
December  and  reaching  its  high  point  in  January  1873,  with  a  monthly  annual 
rate  of  755.  From  this  point  there  was  a  gradual  fall  with  the  culmination  of 
the  epidemic  in  July.  The  annual  death-rates  for  1872  and  1873  were  366 
and  161,  respectively.  This  picture  is,  however,  only  relatively  and  not  actually 
correct,  for  it  is  drawn  from  rates  calculated  only  on  the  deaths  that  occurred 
within  the  city,  no  account  being  taken  of  the  considerable  number  of  deaths 
among  city  cases  sent  to  the  Marine  Hospital  or  pest-house  without  the  city 

Table  36. — Number  of  deaths  and  rate  of  death,  per 
100,000  living  inhabitants,  from  small-pox  and  scar¬ 
let  fever,  according  to  age,  for  1850.  Calculated 
from  figures  given  in  Frick’s  tables. 


Age  period. 

Small-pox. 

Scarlet  fever. 

D 

R 

D 

R 

i 

Under  1  year . 

28 

457 

24 

392 

1  to  4  years . 

48 

260 

134 

727 

5  to  9  years . 

12 

60 

45 

224 

Under  10  years . 

88 

197 

203 

455 

10  to  19  years . 

11 

30 

21 

57. 

20  to  29  years . 

26 

76 

1 

3 

30  to  39  years . 

11 

45 

•  •  • 

•  •  • 

40  to  49  years . 

14 

96 

•  •  • 

•  •  • 

50  to  59  years . 

3 

37 

•  •  • 

•  •  • 

60  years  and  over . 

3 

47 

•  •  • 

•  •  • 

Total  . 

156 

92 

225 

133 

limits.  These  included  many  of  the  worst  cases,  some  of  which  were  moribund 
on  their  arrival.  As  separate  accounts  were  not  reported  of  the  cases  and  deaths 
of  citizens  of  Baltimore  and  of  the  sailors  and  passengers  with  small-pox 
removed  at  quarantine  from  foreign  ships  and  sent  to  the  Marine  Hospital,  it  is 
not  possible  to  determine  the  number  of  deaths  among  the  former  at  that  insti¬ 
tution.  During  the  period  of  the  epidemic  there  were  treated  at  the  Marine 
Hospital  a  total  of  1,016  cases  of  small-pox  with  533  deaths  and  246  cases  of 
varioloid  with  6  deaths,  and  the  great  majority  at  least  of  these  occurred  in 
persons  sent  from  the  city.  There  were  at  the  hospital,  682  cases  of  small-pox 
with  316  deaths  in  1872  and  334  cases  with  217  deaths  in  1873  and  124 
cases  of  varioloid  with  6  deaths  in  the  former  year  and  122  cases  and  no  deaths 
in  the  latter.  The  proportional  distribution  of  the  deaths  of  small-pox  in  the 
city  (1,043  in  1872  and  469  in  1873)  and  at  the  hospital  in  these  two  years  was 
in  the  neighborhood  of  3  to  1  in  1872  and  2  to  1  in  1873.  When  the  number  of 
deaths  occurring  at  the  Marine  Hospital — nearly  all  among  patients  sent  from 
the  city — are  added  to  the  figures  as  given  in  the  official  list,  the  total  number 


FEBRILE  DISEASES 


285 


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■  —I  _ d  _ <  _ l  1  _ l  _ 1  _ l  _ ,  _ 1  _ I  _ i  _ I  _ ■  _ I  _ 1  _ I  -  1  __d  —A  — I  — i 


Those  years  in  which  deaths  did  not  occur  have  been  omitted  from  this  table. 


286  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

of  deaths  attributable  to  small-pox  was  1,365  in  1872  and  686  in  1873,  and  the 
mortality  rates  are  raised  correspondingly  to  479  and  235,  respectively. 

Data  for  the  calculation  of  morbidity  rates  and  case-fatality  rates  in  the 
city  are  unfortunately  lacking.  The  commissioner  of  health,  writing  10  years 
later,  stated  that  in  this  epidemic,  without  compulsory  reporting,  4,000  cases 
of  small-pox  were  discovered  and  probably  as  many  again  were-  concealed ;  6,000 
cases  would  therefore  be  a  conservative  estimate.  According  to  the  report  of 
the  physician  at  the  Marine  Hospital,  the  case-fatality  rate  was  63  per  cent 
among  the  unvaccinated,  and  14  per  cent  among  those  who  had  been  vaccinated. 
Only  3  deaths  occurred  among  individuals  having  “good”  vaccination  marks. 
The  total  case-mortality  rate  for  all  ages  was  40  per  cent  in  1872  and  42  per 
cent  in  1873.  He  calculated  the  case-mortality  rates  as  affected  by  age  for 
both  years.  As  the  results  are  almost  identical,  those  for  1872  are  given  in 
table  38. 

The  high  fatality-rate  among  the  hospital  cases  was  attributed  to  five  sets 
of  causes :  Distant  transportation  over  rough  roads,  the  moribund  condition 
of  many  patients  on  arrival,  the  preponderance  of  negroes,  the  high  proportion 
of  persons  of  the  poorest  conditions  of  life,  and  the  imperfection  of  the 
accommodations  provided.  The  majority  of  the  patients  had  never  been  vacci- 

Table  38. 

p.  c. 


Under  10  years .  48 

10  to  19  years .  35 

20  to  29  years . 38 

30  to  39  years .  43 

40  to  49  years .  35 

50  to  59  years .  52 

60  to  69  years .  66 

70  to  79  years .  60 


nated ;  a  large  number  said  they  had  “  been  vaccinated,  but  it  never  took  ” ;  and 
a  third  class,  in  whom  the  disease  was  lightest,  were  those  who  had  been  vac¬ 
cinated  successfully  in  childhood.  Those  with  good  and  recent  vaccination  scars 
did  not  have  the  disease  severely  enough  to  confine  them  to  bed.  The  favorable 
effect  of  a  previous  attack  of  small-pox  and  of  previous  successful  vaccination 
upon  the  fatality-rate  is  shown  by  the  low  fatality-rates  in  varioloid,  2  per  cent, 
and  in  the  previously  vaccinated,  14  per  cent. 

The  campaign  of  the  health  department,  organized  in  March  1872,  embraced 
(1)  the  reporting  each  morning  by  every  policeman  to  his  district  station  of 
the  cases  discovered  on  his  beat;  (2)  the  prompt  investigation  by  a  medical 
officer  of  the  health  department  detailed  to  each  of  the  four  police  stations  of 
the  new  cases  reported  in  the  district;  (3)  the  employment  of  the  sanitary 
inspectors  to  dispatch  all  cases  willing  to  submit  to  it  to  the  Marine  Hospital, 
to  establish  isolation  in  the  homes  of  cases  not  so  disposed  of  and  in  those  of 
all  contacts,  and  to  supervise  disinfection  of  houses,  clothing,  and  furniture; 
and  (4)  the  vaccination  by  the  regular  vaccine  physicians  of  everyone  who 
would  submit,  whether  previously  vaccinated  or  not,  dwelling  or  working  in 
the  immediate  neighborhood  of  reported  cases.  When,  despite  these  efforts, 
the  disease  continued  to  make  rapid  headway,  a  number  of  extra  vaccine 
physicians  were  ordered  to  enter  each  house  in  the  city,  and,  “baring  every 
arm,  to  vaccinate  everyone  without  unmistakable  evidence  of  thorough  protec- 


FEBRILE  DISEASES 


287 


tive  vaccination,”  whom  they  could  persuade  or  bluff  into  permitting  it.  This 
group  of  vaccinators  are  reported  to  have  made  in  these  two  months  33,911 
separate  calls  and  11,866  vaccinations,  of  which  2,536  wTere  primary,  9,075  were 
secondary,  and  255  unclassified.  The  regular  vaccine  physicians  were  credited 
between  November  1,  1871,  and  October  31,  1872,  with  49,028  calls  and  38,784 
vaccinations,  of  which  10,065  were  primary,  28,240  were  secondary,  and  479 
unclassified.  So  in  this  period,  covering  the  first  12  months  of  the  epidemic, 
public  vaccinators  visited  82,939  dwellings  and  performed  50,650  vaccinations, 
of  which  12,601  were  primary,  i.  e.,  in  persons  never  before  vaccinated;  37,315 
were  secondary,  i.  e.,  in  persons  who  had  been  vaccinated  previously;  and  734 
wrere  not  classified.  Of  a  total  of  19,356  vaccinations  inquired  into  for  success 
or  failure,  14,045  were  recorded  as  successful.  With  the  marked  increase  of 
the  disease  in  January  1873,  the  intensive  campaign  of  vaccination  wras  renewed, 
and  for  the  next  6  months  a  corps  of  80  physicians  assisted  the  regular  vaccine 
physicians.  Between  November  1,  1872,  and  October  31,  1873,  but  for  the 
most  part  between  January  and  July  1873,  these  two  groups  made  96,693  calls, 
with  87,739  vaccinations,  of  which  7,330  were  classed  as  primary  and  80,409 
as  secondary.  Thus,  during  this  period  of  Baltimore’s  greatest  epidemic  of 
small-pox,  the  20  months  between  November  1871  and  July  1873,  inclusive, 
there  were  made  by  public  vaccinators  179,632  calls,  138,389  vaccinations, 
of  which  19,931  were  classified  as  primary  and  117,724  as  secondary.  In  other 
words,  the  calls  wrere  in  proportion  of  nearly  4  to  each  family,  the  vaccinations 
nearly  1  for  each  2  persons  in  the  population,  and  about  one-sixth  of  the  vaccina¬ 
tions  were  primary  and  five-sixths  secondary. 

It  is  not  improbable  that  many  of  the  secondary  vaccinations  were  in  individ¬ 
uals  who  had  been  inoculated  with  vaccine  material  but  not  successfully,  some 
in  childhood  and  others  since,  and  even  during  the  epidemic,  and  are  therefore 
not  to  be  considered  as  true  revaccinations,  i.  e.,  vaccinations  of  persons  who 
had  previously  undergone  successful  vaccination.  From  these  figures  it  would 
appear  that  somewhat  less  than  half  the  individuals  of  the  average  population 
for  these  two  years  (138,000  out  of  287,000)  were  accounted  unprotected  by 
previous  vaccination,  and  that  of  these  nearly  20,000,  or  about  7  per  cent,  had 
never  been  vaccinated. 

Early  in  the  epidemic  it  was  determined  that  the  virus  furnished  by  the  State 
was  not  potent,  and  new  virus  was  obtained  from  other  sources.  It  is  known 
that  many  of  the  vaccinations  were  made  with  “  crusts,”  which,  in  the  opinion 
of  the  commissioner  of  health,  were  often  not  so  cut  that  the  virus  would  be 
properly  applied.  To  what  extent  vaccination  was  carried  on  by  private  physi¬ 
cians  is  not  known,  but  it  is  not  unlikely  that  the  number  covered  a  large 
proportion  of  those  found  with  satisfactory  vaccination  marks.  A  factor  that 
militated  against  frequency  of  private  vaccinations  even  among  a  considerable 
proportion  of  the  more  intelligent  and  better-to-do  portion  of  the  population 
was  the  fact  that  a  large  moiety  of  the  special  vaccine  physicians  were  men  of 
prominence,  to  whom  their  regular  patients  would  have  applied  had  they  not 
received  the  same  services  from  them  in  their  public  capacity.  By  the  end  of  this 
epidemic,  all  but  a  small  proportion  of  the  population  had  been  submitted  to 
vaccination. 

During  the  years  1874  to  1880,  the  city  was  almost  free  from  small-pox. 
Though  there  was  a  death  from  the  disease  in  4  of  the  7  years,  it  showed  no 


288  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


tendency  to  spread.  In  1881,  small-pox  was  credited  with  1  death  in  May  and 
another  in  June,  after  which  the  disease  apparently  died  out.  It  reappeared 
in  November,  causing  5  deaths  each  in  this  month  and  in  December,  and  this 
marked  the  beginning  of  a  severe  epidemic  that  lasted  until  July  1883.  Between 
January  1882,  and  the  latter  date  there  were  reported  4,939  cases  and  1,184 
deaths  within  the  city,  and  to  these  there  are  to  be  added  the  359  deaths  among 
the  1.053  patients  sent  from  the  city  to  the  Marine  Hospital  during  the 
epidemic.  Through  the  13  months  from  January  1882,  as  is  strikingly  shown 
in  tables  31  and  39,  the  disease  grew  in  incidence  and  in  fatality  in  steady 
and  almost  uninterrupted  progression,  apparently  uninfluenced  by  season  or 
by  vaccination.  The  curves  for  morbidity  and  mortality  would  correspond  even 
more  closely  were  it  possible  to  add  the  deaths  occurring  at  the  hospital  properly 
distributed  as  to  date  of  occurrence.  After  January  1883,  the  descent  of  the 


Table  39. — Monthly  morbidity  and  mortality,  and  respective  rates,  per  100,000  living 
inhabitants,  from  small-pox,  during  the  epidemic,  1882-1883. 


O  =  cases.  D  =  death.  It  =  rate. 


1S82 

1883 

C 

R 

D 

R 

C 

R 

D 

R 

Jan . 

46 

154 

2 

7 

1259 

4119 

329 

1076 

Feb . 

53 

196 

6 

22 

542 

1964 

194 

703 

Mar . 

38 

127 

10 

33 

175 

573 

65 

213 

Apr . 

78 

269 

12 

41 

92 

311 

28 

95 

May  . 

107 

357 

17 

57 

35 

115 

12 

39 

J une  . 

106 

366 

13 

45 

9 

30 

4 

14 

July  . 

114 

381 

22 

73 

2 

7 

1 

3 

Aug . 

237 

791 

24 

80 

•  •  •  • 

Sept . 

255 

880 

71 

245 

•  •  •  • 

Oct . 

362 

1209 

63 

210 

»  •  •  • 

Nov . 

483 

1666 

94 

324 

*  •  •  • 

Dec . 

946 

3158 

217 

724 

.... 

Total  . 

2825 

801 

551 

156 

2114 

587 

633 

176 

curves  is  rapid,  such  as  would  have  occurred  had  the  disease  used  up  its  available 
material  or  had  its  progress  been  checked  by  definite  interference.  It  is  evident 
that  this  epidemic  was  by  no  means  so  severe  as  that  of  1872-1873  as  expressed 
in  death-rates. 

This  epidemic  was  fought  by  the  same  commissioner  of  health  and,  with  two 
important  additions,  with  the  same  means  and  methods.  The  only  differences 
were  that  in  October  1882  small-pox  was  made  reportable,  and  the  commissioner 
of  health  was  given  broad  powers  to  enforce  vaccination  and  revaccination, 
to  compel  isolation  and  hospitalization  of  those  sick  with  small-pox,  to  control 
funerals,  to  restrict  the  use  of  public  vehicles,  and  to  disinfect  dwellings, 
furniture,  and  clothing.  Only  8  years  before  a  very  general  vaccination,  which 
must  have  embraced  at  least  two-thirds  of  the  population,  had  been  practiced, 
and  under  the  influence  of  the  slight  outbreak  of  small-pox  in  May  and  June 
and  the  reappearance  of  the  disease  in  November  and  December  1881,  vaccina¬ 
tion,  as  is  shown  by  the  decided  rise  in  the  vaccination-rate,  was  stimulated. 


FEBRILE  DISEASES 


289 


In  March  1882,  and  after  the  epidemic  was  well  under  way,  the  commissioner 
of  health  started  his  force  of  regular  vaccine  physicians,  now  increased  to  17 
in  number,  on  house-to-house  visits  in  accordance  with  the  established  custom 
to  vaccinate  and  revaccinate  those  who  would  submit.  Apparently  unaffected 
by  the  measures  employed  or  by  the  season,  the  number  of  cases  and  deaths 
continuing  to  mount,  52  extra  vaccine  physicians  were  employed  in  August  and 
September.  The  slight  lag  in  the  curves  of  morbidity  and  mortality  in  October 
may  be  taken  to  reflect  some  restraining  influence  attributable  to  this  activity, 
but  such,  if  present,  was  only  temporary.  The  extra  vaccine  physicians  were 
called  into  action  again  in  December,  now  with  compulsory  powers.  In  the 
calendar  year  the  regular  vaccine  physicians  were  credited  with  40,226  calls  and 
53,290  vaccinations,  of  which  13,553  were  primary  and  39,737  were  secondary. 
Of  these  vaccinations,  15,954  were  in  colored  and  37,336,  in  whites,  or  in  a 
proportion  of  nearly  1  to  2  where  the  proportion  of  colored  to  white  in  the 
population  was  1  to  5.5.  Of  20,935  vaccinations  investigated  as  to  success  or 
failure,  15,528  were  recorded  as  successful.  The  extra  vaccine  physicians  per¬ 
formed  41,403  vaccinations,  of  which  4,652  were  primary.  In  January  1883, 
previous  efforts  having  failed  to  check  the  disease,  50  additional  vaccine  physi¬ 
cians  were  appointed,  making  119  vaccine  physicians,  all  under  the  charge  of 
Dr.  I.  E.  Atkinson,  as  supervisor  of  vaccinations.  Furnished  with  a  new  supply 
of  the  “  purest  animal  virus,  the  large  force  of  physicians  was  massed  in  those 
localities  where  the  disease  prevailed  to  the  greatest  extent,  visiting  every  house 
consecutively,  baring  every  arm,  and  vaccinating  and  revaccinating  everyone, 
old  and  young,  that  did  not  present  unmistakable  evidence  of  recent,  thorough, 
and  protective  vaccination.”  This  time,  under  the  direction  of  a  talented  and 
trained  clinician,  fearless  and  determined,  fortified  now  with  the  requisite 
legal  powers,  vaccinations  were  performed  nolens,  volens.  When  by  March  there 
was  a  marked  diminution  of  the  numbers  of  reported  cases  and  deaths,  two- 
thirds  of  the  extra  force  was  discharged.  The  spread  of  the  disease  declined 
rapidly  and  the  last  case  was  discharged  in  July.  In  this  year,  and  chiefly 
during  the  first  6  months,  the  regular  vaccine  physicians  performed  26,673 
vaccinations,  2,628  of  which  were  primary  and  24,045  were  secondary,  while 
the  extra  vaccine  physicians  performed  190,377  vaccinations,  of  which  15,236 
were  primary  and  175,141  were  secondary. 

Some  idea  of  the  extent  of  vaccination  in  the  city  at  this  time  is  conveyed  by 
the  following  figures:  In  a  total  population  of  352,674,  the  public  vaccinators, 
regular  and  extra,  vaccinated  between  January  1,  1882,  and  July  1,  1883, 
some  311,743  persons  (or  the  whole  population  with  the  exception  of  40,931), 
and  of  these,  38,697  were  primary  and  273,046  were  secondary  vaccinations. 
A  large  proportion  of  the  40,931  persons  not  so  vaccinated  were  presumably 
passed  by  the  public  vaccinators  because  they  had  been  recently  vaccinated 
successfully  by  private  physicians.  Therefore,  disregarding  these,  only  about  12 
per  cent  of  the  311,743  persons  covered  by  the  records  had  never  been  vaccinated. 
So  it  would  appear  that  at  that  time  vaccination  had  been  so  widely  practiced 
that  between  85  and  90  per  cent  of  the  population  had  been  submitted  to  appar¬ 
ently  successful  vaccination.  Of  the  79,963  vaccinations  (16,181  primary,  and 
63,782  secondary)  performed  by  the  regular  vaccine  physicians,  28,847  were 
investigated  as  to  success  or  failure,  and  of  these  21,930  were  recorded  as 
successful  and  6,917  as  unsuccessful,  whence  it  would  appear  that  if  all  the 


290  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

primary  vaccinations  be  granted  to  be  successful,  5,749  of  the  63,782  secondary 
vaccinations,  or  about  9  per  cent,  “took”  and  consequently  something  like  10 
per  cent  of  the  previously  vaccinated  members  of  the  population  were  susceptible 
to  small-pox  on  exposure.  Now,  of  the  4,939  cases  of  small-pox  reported  during 
this  epidemic,  2,858,  or  about  58  per  cent  are  recorded  to  have  occurred  among 
those  previously  vaccinated,  and  2,081,  or  42  per  cent,  among  the  unvaccinated; 
so  if  the  40,000-odd  persons  presumably  vaccinated  by  private  physicians  be 
apportioned  as  unvaccinated  and  previously  vaccinated  as  1  to  7  respectively, 
there  would  have  been  in  the  population  approximately  43,697  persons  of  the 
former  and  59,574  of  the  latter  category  (arrived  at  as  follows:  Total  number 
of  primary  vaccinations  38,697  +  5,000  =  43,697,  and  9  per  cent  of  273,046  = 
24,574,  and  24,574  +  35,000  =  59,574),  from  which  it  would  appear  that  the 
attack-rate  was  6,540  per  100,000  persons  among  the  non-vaccinated  and  3,493 
per  100,000  among  persons  previously  vaccinated  but  whose  immunity  had 
lapsed.  Of  the  2,858  cases  among  those  previously  vaccinated  there  was  a 
fatality  of  327,  or  11  per  cent,  and  of  the  2,081  cases  among  the  non-vaccinated, 
839,  or  40  per  cent,  the  total  rate  being  24  per  cent.  These  rates  for  non- 
vaccinated  and  for  total,  at  least,  are  lower  than  the  true  rates,  for  in  calculating 
them  the  deaths  occurring  among  those  sent  to  the  Marine  Hospital  were  not 
included  in  the  tables  of  the  commissioner  of  health.  Including  the  359  deaths 
among  the  1,053  cases  sent  to  the  Marine  Hospital  in  1882  and  1883,  the  total 
fatalities  were  1,543,  with  a  case  fatality  of  31.3  per  cent.  During  this  epidemic 
the  case-fatality  rate  among  the  cases  at  the  Marine  Hospital  was  decidedly 
lower  than  in  the  epidemic  of  1872-1873. 

Twenty  years  elapsed  (1902)  before  there  was  a  serious  threat  of  epidemic 
small-pox,  and  in  only  three  of  these  years  (1884,  1886,  and  1899)  were  there 
deaths  registered  against  this  disease  in  the  city.  In  each  of  these  years  there 
was  a  single  death.  However,  there  were  during  these  20  years  numerous 
occasions  when  cases  were  imported  and  the  disease  spread  to  a  few  contacts. 
Such  cases  were  almost  invariably  sent  to  the  quarantine  hospital  and  the 
deaths  among  them  not  charged  to  the  city.  Mortality-rates  averaged  for  5- 
and  10-year  periods  are  given  in  table  43  (page  301)  and  graphs  12  and  16. 

Only  since  1899  are  the  records  of  reported  cases  given  in  the  annual  reports. 
The  morbidity  reports  from  this  date  (table  40)  show,  however,  that  in  but  a 
single  year  (1916)  has  the  disease  failed  to  show  itself.  In  some  years,  as  in 
1902  to  1904  and  in  1913  to  1914,  the  number  of  reported  cases  has  been  suffi¬ 
cient  to  warrant  the  use  of  the  term  epidemic. 

It  will  be  noted  that  beginning  with  1890  there  was  for  some  years  a  marked 
increase  in  the  vaccination-rates.  These  reached  rather  high  levels  in  years  of 
actual  or  threatened  epidemic.  The  State  law  regarding  the  admission  of  un¬ 
vaccinated  children  to  schools  remained  a  dead  letter  until  after  the  inaugura¬ 
tion  of  school  inspection  in  1908. 

From  the  monthly  tables  of  reported  cases  since  1899  (table  40)  and  of 
deaths  from  1856  to  1914  (table  37),  and  the  monthly  annual  rates  calculated 
therefrom,  the  influence  of  season  on  the  incidence  and  mortality  from  small¬ 
pox  is  clearly  shown.  With  hardly  an  exception,  the  heaviest  morbidity  has 
been  in  the  cold  months,  and  a  characteristic  of  the  course  of  the  disease,  when 
present,  has  been  a  rise  in  incidence  and  death-rates  during  the  fall  to  an  acme 


FEBKILE  DISEASES 


291 


Table  40. — Morbidity  by  months  and  years  and  the  monthly  annual  and  annual  rates 
of  morbidity,  per  100,000  living  inhabitants,  from  small-pox,  from  1897  to  1920, 
inclusive .* 


O  =  cases.  R  =  rate. 


Jan. 

Feb. 

Mar. 

Apr. 

May. 

June. 

July. 

Year. 

C 

R 

C 

R 

C 

R 

C 

R 

C 

R 

C 

R 

C 

R 

1899  . 

2 

5 

2 

5 

7 

16 

2 

5 

3 

7 

1 

2 

1900  . 

9 

22 

2 

5 

3 

7 

1 

2 

1901  . 

3 

7 

1 

3 

4 

9 

1 

2 

2 

5 

1 

2 

1902  . 

14 

35 

3 

7 

3 

7 

5 

11 

1 

2 

1903  . . . 

2 

4 

6 

15 

10 

22 

5 

12 

13 

29 

1 

2 

1 

2 

1904  ... 

1 

2 

4 

10 

9 

20 

14 

32 

20 

44 

10 

23 

•  • 

•  •  • 

1905  ... 

... 

1906  ... 

14 

30 

19 

45 

14 

30 

9 

20 

2 

4 

1907  ... 

2 

5 

1 

2 

1908  . . . 

1 

2 

2 

5 

•  •  • 

•  •  • 

1 

2 

1 

2 

•  • 

• 

1 

2 

1909  . . . 

1910  ... 

1 

2 

1 

2 

1911  . 

1 

2 

1912  . .. 

1913  ... 

27 

54 

13 

287 

1 

2 

•  •  • 

•  •  • 

2 

4 

1 

2 

2 

4 

1914  ... 

29 

57 

82 

179 

143 

283 

44 

90 

15 

30 

11 

22 

1 

2 

1915  ... 

12 

23 

1917  . 

2 

4 

7 

13 

3 

6 

1918  ... 

7 

13 

5 

11 

10 

19 

10 

20 

9 

17 

5 

10 

#  # 

•  •  • 

1919  ... 

1 

2 

9 

15 

4 

7 

3 

5 

1 

2 

1920  . 

4 

6 

5 

9 

2 

3 

10 

17 

6 

10 

4 

7 

1 

2 

Aug. 

Sept. 

Oct. 

Nov. 

Dec. 

Total. 

Per  cent, 
case  fatality. 

Year. 

C 

R 

C 

R 

C 

1 

R 

C 

R 

C 

R 

C 

R 

Average 
rate  of 
morbid¬ 
ity  by 
5-year 
periods. 

Annual. 

Aver¬ 
age  by 
5-year 
periods 

1899  . . 

1 

2 

18 

4 

6 

1900 

1 

2 

1 

2 

17 

3 

2 

1 

1901  . . 

1 

2 

1 

2 

14 

3 

1902  . . 

2 

5 

1 

2 

29 

6 

24 

1903  . . 

1904  .. 

1 

2 

1 

2 

1 

2 

41 

8 

9 

5 

58 

11 

7 

1905  . . 

3 

7 

19 

41 

22 

4 

6 

7 

1906  . . 

58 

11 

1907  . . 

1 

2 

4 

1 

1908  . . 

6 

1 

1909  . . 

2 

4 

2 

1910  . . 

2 

3 

1911  .. 

1 

1912 

4 

8 

11 

22 

15 

3 

1913  . . 

3 

6 

1 

2 

50 

8 

1914  .. 

325 

55 

1 

1915  .. 

12 

2 

14 

1917  .. 

1 

2 

10 

19 

23 

38 

1918  . . 

46 

7 

1919  . . 

18 

3 

1920  . . 

2 

3 

34 

5 

10 

*  Those  years  in  which  cases  did  not  occur  have  been  omitted  from  this  table. 


292  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

in  the  winter  or  spring,  followed  by  a  decline  to  a  low  point,  even  to  complete 
disappearance,  during  the  hot  weather. 

The  well-known  association  of  increase  in  the  spread  and  virulence  of  small¬ 
pox  with  w^ars  suggests  examination  of  the  recorded  experience  of  Baltimore  in 
this  connection.  For  this  purpose  it  will  be  convenient  to  compare  the  time 
relationships  of  the  chief  local  epidemic  outbreaks  with  the  occurrence  of  wars 
in  America  and  elsewhere.  The  epidemic  of  1811  to  1812  coincides  with  the 
Napoleonic  wars  in  Europe,  and  the  last  year  with  the  first  year  of  the  Anglo- 
American  War  of  1812-1815.  No  great  war  wyas  being  waged  in  Europe  or 
America  just  previous  to  1821.  The  uprising  in  Europe  in  connection  with 
Belgium  and  the  beginning  of  the  struggle  of  Italy  for  freedom  correspond 


Graph  12  (from  table  43).  Crude  mortality  rates  from  small-pox,  varicella, 
and  influenza,  averaged  by  5-year  periods,  from  1812  to  1920,  inclusive. 


with  the  outbreak  of  small-pox  in  1831-1834,  and  the  Italo- Austrian  struggle 
may  be  cited  in  relation  to  that  of  1837-1838.  The  epidemic  of  1845-1846 
preceded  our  war  with  Mexico;  that  of  1849-1852  followed  closely  it  and  the 
disturbances  in  Europe  in  1848;  and  the  epidemics  of  1854-1855  and  1857- 
1858  occurred  shortly  after  the  Crimean  War  and  the  accentuation  of  the 
Italian  struggle.  There  was  a  distinct  coincidence  between  the  epidemics  of 
1862-1865  and  1871-1873,  and  the  American  Civil  and  the  Franco-Prussian 
Wars,  respectively.  The  great  outbreak  of  1881-1883  may  possibly  have  been 
related  to  increased  prevalence  of  small-pox  in  association  with  the  Russo- 
Turkish  War,  and  the  Balkan  troubles  and  the  British  attack  on  Egypt,  and 
it  is  likewise  possible  that  there  was  a  relationship  between  the  slight  epidemic 
of  1902-1904,  and  1912-1914  with  the  Spanish-American  War  of  1898  and 
the  Anglo-Boer  War  of  1899-1902,  and  the  Balkan  Wars  of  1912. 


FEBRILE  DISEASES 


293 


However,  the  coincidence  in  time  between  two  events  is  only  suggestive  and 
falls  far  short  of  proof  that  one  holds  a  causal  relationship  to  the  other.  There 
is  little  doubt  that  the  Napoleonic  Wars  were  responsible  for  spreading  small¬ 
pox  over  central  Europe  and  thence  to  America,  that  small-pox  in  virulent  form 
spread  widely  in  Europe  and  in  America  during  and  after  the  Franco-Prussian 
War,  and  that  in  both  instances  the  troops  were  primarily  responsible  for  spread 
of  this  disease.  That  there  was  considerable  small-pox  for  a  time  in  the  Ameri¬ 
can  Civil  War  and  that  Baltimore  was  favorably  situated  for  infection  is  true, 
and  it  is  very  likely  that  the  local  epidemic  of  that  time,  in  some  measure  at 
least,  was  of  this  origin.  However,  until  the  last  two  decades  of  the  nineteenth 
century,  small-pox  was  prevalent  in  many  countries  in  Europe,  and  particularly 
those  countries  from  which  immigrants  come  to  Baltimore;  and  furthermore, 
Europe  was  rarely  entirely  free  from  war. 

The  history  of  small-pox  in  Baltimore  presents  some  striking  features  from 
which  may  be  drawn  instructive  information  in  regard  to  the  natural  history 
of  the  disease  and  valuable  lessons  in  public-health  administration.  The  first 
concerns  the  endemic  and  epidemic  states  of  the  disease  in  the  community. 
While  it  is  true  that,  unlike  other  members  of  the  group,  from  the  earliest 
times  its  natural  course  has  been  modified  by  artificial  interferences  with  its 
entrance  and  spread  in  the  city,  enough  is  known  of  the  value  of  these  at  differ¬ 
ent  periods  to  allow  for  their  discount  with  some  measure  of  certainty.  Between 
1800  and  1830,  when  the  use  of  inoculation  and  of  vaccination  were  compara¬ 
tively  restricted  and  quarantine  and  general  methods  designed  to  prevent  its 
spread  among  the  inhabitants  were  of  the  most  meager  sort,  the  disease  occurred 
repeatedly  in  small  and  twice  in  large  outbreaks  without  becoming  endemically 
established.  On  the  other  hand,  between  1831  and  1866,  in  association  with 
much  wider  use  of  vaccination  and  of  restrictive  measures  of  a  general  sort, 
small-pox  was  very  commonly,  if  not  constantly  endemic.  During  this  period 
upon  this  endemic  state  there  were  imposed  a  number  of  periodic  epidemic 
waves,  which  were  not  usually  associated  with  mortality  rates  as  high  for 
individual  years  as  were  those  experienced  before  and  later.  Between  1867 
and  1883  this  phase  was  succeeded  by  a  return  to  the  conditions  prevailing 
before  1830,  when  the  disease  was  no  longer  endemically  established,  but 
appeared  only  from  time  to  time,  with  two  very  serious  epidemics  (1872-1873 
and  1882-1883)  separated  by  an  interval  of  10  years. 

These  two  epidemic  visitations,  with  mortality  rates,  when  proper  allow¬ 
ances  for  deaths  occurring  at  the  small-pox  hospital  are  made,  much  higher 
than  ever  before  experienced,  occurred  after  a  period  of  increased  public  vacci¬ 
nation-rates,  the  establishment  of  a  State  vaccine  institution  for  the  propagation 
of  potent  virus,  the  passage  of  State  laws  requiring  compulsory  vaccination  of 
infants,  and  the  exclusion  of  unvaccinated  children  from  school.  As  neither 
of  these  legal  provisions  was  systematically  obeyed  (the  commissioner  of  health 
discarded  the  State  virus  as  impotent  in  1872),  any  effects  which  would  in 
theory  be  credited  to  them  must  be  largely  discounted  in  practice.  However, 
in  spite  of  these  activities  as  planned  and  executed  and  of  the  most  active  and 
widespread  vaccination  campaigns  ever  conducted  in  the  city,  these  two  epi¬ 
demics  lasted  for  the  usual  period  of  18  or  20  months  and,  relative  to  the 
population,  were  even  severer  in  degree  than  any  of  their  predecessors. 


294  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


Since  1884,  small-pox  has  taken  on  a  new  phase,  one  which  is  without  parallel 
in  previous  experience.  Though  introduced  many  times,  and  since  1897 
present  each  year,  the  disease  has  not  acquired  endemic  status  and  has  only 
twice  (1902-1904  and  1912-1914)  threatened  to  become  seriously  epidemic. 
While,  owing  to  the  fact  that  most  of  those  ill  of  the  disease  have  of  late  years 
been  removed  to  quarantine  hospitals  without  the  city,  the  deaths  officially 
credited  to  small-pox  by  no  means  represent  the  actual  fatality;  nevertheless, 
the  number  has  been  small,  and  in  comparison  with  earlier  periods  almost 
negligible.  During  this  period  vaccination  has  increased,  virus  has  been  greatly 
improved,  and  case-reporting  and  isolation  have  been  secured.  Another  factor 
of  considerable  importance  is  that  since  1884  the  bulk  of  the  European  immi¬ 
grants  has  come  from  countries  where  vaccination  was  enforced,  while  previous 
to  this  date  the  contrary  was  the  case.  Since  1900,  at  least,  the  disease  has 
been  introduced  almost  entirely  by  negroes  from  the  South,  and  has  been 
largely  confined  to  this  race. 

It  is  of  considerable  interest  that  severe  epidemic  outbreaks  have  tended  to 
occur  at  about  10-year  intervals  falling  at  or  near  the  beginning  of  decennia, 
as  in  1811,  1821,  1831,  1850,  1862,  1872,  1882,  1902,  and  1912. 

It  seems  clear  that  until  1884  the  prevalence  and  mortality  of  small-pox 
were  governed  to  a  much  greater  degree  by  its  inherent  natural  characteristics 
in  their  relation  to  the  population,  than  by  any  artificial  interferences,  including 
vaccination,  that  were  interposed.  It  appears  that  before  1900  the  course  of  the 
disease  could  have  been  only  modified  and  not  controlled  by  vaccination  as 
practiced. 

When  the  curves  of  the  rates  for  small-pox  mortality  and  public  vaccination 
incidence  are  compared,  it  is  evident  that,  as  a  rule  to  which  there  are  striking 
exceptions,  vaccination  was  considerably  stimulated  by  the  unusual  presence 
of  small-pox. 

The  want  of  perception  on  the  part  of  the  people  in  withholding  from  the 
health  department  powers  which  experience  had  repeatedly  shown  to  be  neces¬ 
sary  for  adequate  protection  against  small-pox  is  one  of  the  most  important 
features  in  the  public-health  history  of  Baltimore.  Though  almost  always  under 
the  shadow  of  this  dread  disease  and  frequently  experiencing  severe  epidemics, 
and  with  ample  evidence  that  the  voluntary  system  was  a  failure,  it  was  only 
by  gradual  stages  that  the  compulsory  system  was  adopted.  Not  until  1882 
was  the  commissioner  of  health  given  the  powers  demanded  as  essential  by 
Dr.  Jameson  in  1832,  and  not  until  30  years  later  was  vaccination  generally 
enforced  to  a  point  of  reasonable  but  still  far  short  of  perfect  security  against 
small-pox.  As  a  matter  of  fact,  it  was  not  until  over  100  years  after  the  dis¬ 
covery  of  vaccination  and  the  introduction  of  the  method  in  Baltimore  that  it 
was  given  a  test  even  approximately  fair. 

The  proposal  in  1820  to  make  small-pox  cases  compulsorily  reportable  was 
successfully  restrained  by  the  physicians,  and  this  evidently  reasonable  pro¬ 
cedure  was  postponed  until  1882. 

Hardly  less  reprehensible  was  the  inhuman  treatment  of  the  poor  victims  of 
small-pox  who  were  dragged  in  rough  wagons  over  rougher  roads  in  all  weathers 
to  the  “  Marine  Hospital,”  which,  according  to  the  mistaken  idea  of  the  times, 
was  situated  in  the  most  inaccessible  of  places.  It  is  no  wonder  that  some 


FEBRILE  DISEASES 


295 


perished  on  the  way  and  that  many  were  moribund  on  arrival.  Less  barbarous, 
but  equally  unnecessary,  has  been  the  later  custom  still  in  vogue  of  transporting 
small-pox  patients  by  water  to  the  present  quarantine  station,  where  the  accom¬ 
modations  furnished  by  the  city  can  scarcely  be  dignified  by  the  term  hospital. 

It  will  be  understood  that,  before  1827,  the  vaccinations  performed  by  the 
public  vaccinators  represented  only  those  made  on  the  poor  who  desired  it, 
but  were  unable  to  pay  the  modest  charges  demanded  by  private  physicians. 
In  this  year  and  until  1882,  in  addition  to  these  were  included  the  compulsory 
vaccinations  of  those  in  the  immediate  neighborhood  of  known,  cases  of  small¬ 
pox.  After  the  great  campaign  of  compulsory  vaccinations  in  1882-1883,  the 
services  of  the  public  vaccinators  were  available  to  all  who  might  apply,  and 
the  vaccine  physicians  have  kept  special  office  hours  for  the  purpose.  These 
services  of  late  years,  especially  since  the  system  of  school  inspection  has  made 
it  possible  to  compel  vaccination  of  all  school  children,  have  been  widely 
accepted.  With  the  exception  of  special  drives  now  and  then  directed  against 
known  contacts  with  small-pox  cases,  this  is  the  only  compulsion  now  exercised 
over  vaccination.  Since  granted  the  power  in  1882,  the  commissioners  of 
health  have  but  rarely  ordered  vaccination  and  revaccination.  The  State  law 
regarding  the  vaccination  of  infants  in  their  first  year  of  age  has  been  and  is  a 
dead  letter. 

Concerning  the  question  of  vaccinations  by  private  physicians,  it  is  safe  to 
say  that  probably  by  1814,  and  certainly  by  1821,  in  the  bulk  of  the  well-to-do 
families  in  the  clientele  of  physicians  of  the  better  type,  the  children  were 
routinely  vaccinated  in  infancy,  and  in  many  cases  revaccination  was  practiced 
at  puberty,  and  often  later  in  life,  particularly  in  times  of  small-pox  epidemics, 
which  were  abundant  enough  until  after  1884.  Among  such  people  there  has 
probably  been  but  little  neglect  in  this  regard,  and  they  have  passed  safely 
through  the  various  epidemics.  Among  the  whites,  it  has  been  the  newest  immi¬ 
grant  who  has  neglected  to  protect  himself  and  his  family.  This  was  particu¬ 
larly  marked  in  the  Irish  and  German  immigrants,  who  were  unaccustomed  to 
general  vaccination  at  home.  The  Bohemians,  among  more  recent  immigrants, 
were  unfamiliar  with  vaccination.  Among  the  Poles  and  Polish  Jews  vaccina¬ 
tion  was  common,  and  the  latter  regularly  present  their  children  for  vaccina¬ 
tion  in  May.  Doubtless  the  slave  negroes  were  commonly  vaccinated.  But 
above  all,  it  has  been  the  free  negro,  both  before  and  since  the  Civil  War, 
who  has  contributed  the  largest  quota  to  the  army  of  the  unvaccinated.  Among 
these,  those  in  domestic  service  have  in  the  main  accepted  vaccination,  partly 
from  example  and  partly  because  employers  demanded  it.  A  third  but  relatively 
small  group,  composed  of  white  persons  of  native  birth  from  other  States,  in 
many  other  respects  apparently  rational,  have  avoided  vaccination  for  their 
children  and  themselves  on  various  grounds.  Eeports  of  the  school  inspectors 
showed  in  1911  but  5  per  cent  and  in  1918  less  than  1  per  cent  of  the  children 
in  the  public  and  parochial  schools  had  not  been  successfully  vaccinated. 

“  Crusts  ”  were  much  in  vogue  as  late  as  1872  and  were  employed  to  some 
degree  until  much  later.  Smith’s  virus  was  probably  in  continuous  use  for  many 
years.  The  health  department’s  virus,  the  dependence  of  the  vaccine  physicians 
and  probably  collected  by  them,  was  jealously  guarded  and  was  freely  dispensed. 
In  1832,  1843,  and  1846  it  was  “  renewed  ”  by  passage  through  the  cow.  The 


296  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

State’s  virus  was  discarded  as  impotent  by  the  health  department  in  1872,  and 
since  that  date  the  city  health  department  has  purchased  virus  from  commercial 
firms.  The  large  proportion  of  the  cases  of  small-pox,  G8  per  cent,  reported  by 
the  physicians  in  charge  at  the  Marine  Hospital  as  occurring  in  1872  among  the 
previously  vaccinated,  and  with  considerable  but  relatively  low  fatalities  as 
compared  with  the  unvaccinated,  attests  to  previous  use  of  virus  of  low  potency. 
Prior  to  1904,  when  the  Public  Health  Service  undertook  supervision  of  com¬ 
mercial  virus,  much  of  this  was  perhaps  either  impotent  or  at  least  of  poor 
grade.  As  the  results  were  under  the  constant  observation  of  the  vaccine  physi¬ 
cians,  however,  who  would  report  poor  virus,  it  was  probably  usually  superior 
to  the  virus  purchased  through  most  druggists.  Of  late  years  the  health  depart¬ 
ment  has  dispensed  in  large  quantities  freely  to  physicians  a  pure  and  highly1 
potent  vaccine  virus  purchased  by  contract  from  commercial  firms. 

CHICKEN-POX. 

Just  when  chicken-pox  was  first  introduced  into  Baltimore  and  when  it 
became  endemic  is  not  known.  No  deaths  were  recorded  before  1821,  and  cases 
were  not  reported  routinely  until  1897.  There  is  every  reason  to  think  that 
varicella  has  been  prevalent  since  at  least  the  beginning  of  the  nineteenth 
century.  Judging  from  the  annual  mortality  rates  (table  34,  graph  11),  it 
was  somewhat  more  fatal  in  the  earlier  years  than  in  the  recent  years  embraced 
in  the  records,  but  at  no  time  has  it  contributed  significantly  to  the  lists  of 
deaths.  From  the  morbidity  reports  since  1897  (table  41),  it  would  appear 
that  this  disease  has  become  progressively  more  prevalent,  and  it  might  be 
argued  with  some  reason  that  it  runs  in  waves  of  incidence  like  others  of  this 
group.  Because  of  the  probability  of  confusion  in  diagnosis  between  small-pox 
and  chicken-pox,  the  almost  constant  presence  of  the  former  during  this  period 
has  stimulated  the  reporting  of  cases  of  the  latter  when  seen  by  physicians. 
However,  varicella  is  so  mild  that  in  many  cases  physicians  are  not  summoned, 
and  to  the  ignorant  even  small-pox  is  not  a  menace.  Much  more  likely  is  it 
that  the  increase  in  the  morbidity  of  chicken-pox  is  due,  in  largest  part  at 
least,  to  more  accurate  reporting  of  cases  during  the  past  10  years,  under  the 
pressure  exercised  by  the  health  department.  In  this  connection  it  may  be 
pointed  out  that  the  morbidity-rates  do  not  indicate  that  the  efforts  made  dur¬ 
ing  this  period  to  restrict  the  spread  of  this  disease  have  affected  its  course. 

The  monthly  annual  morbidity-rates  (table  41)  indicate  very  clearly  the 
influence  of  season  upon  the  prevalence  of  the  disease.  From  the  midsummer 
low  point,  usually  August,  but  in  some  years  J uly  and  in  others  September,  the 
wave  of  incidence  commonly  ascends  smoothly  to  a  peak  reached  in  January 
or  February  and  declines  in  much  the  same  gradual  manner  during  the  succeed¬ 
ing  months  to  complete  the  12-month  cycle.  Whether  the  number  of  cases 
reported  is  greater  or  smaller,  the  same  relative  distribution  to  season  is  con¬ 
stantly  repeated.  Previous  to  1921,  there  are  no  data  for  determining  the 
influence  of  race,  sex,  and  age  upon  the  incidence  of  this  disease.  Rates  specific 
for  these  categories  in  this  year  are  presented  in  table  42.  It  will  be  noted 
that  of  the  total  of  1,938  cases,  1,700  were  in  individuals  below  the  tenth  year 
of  age,  and  that  the  rate  in  the  second  was  double  that  in  the  first  five  years 
of  life.  During  the  first  year  of  life,  when  the  rates  were  relatively  low,  there 


Table  41. — Morbidity  by  months  and  years  and  the  monthly  annual  and  annual  rates  of  morbidity,  per  100,000  living  inhabitants,  from  varicella, 

from  1897  to  1920,  inclusive. 


FEBRILE  DISEASES 


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298  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


was  no  significant  difference  in  morbidity  among  whites  and  negroes,  and  in 
respect  of  the  two  sexes  the  difference  was  not  great.  However,  the  highest 
rates  occurred  in  white  males  and  the  lowest  in  white  females.  From  1  to  4 

Table  42. — Number  of  cases  and  rate  of  morbidity,  per  100,000  living  inhabitants  in 
1920,  for  chicken-pox  and  mumps,  according  to  age,  color,  and  sex,  for  1921. 

C  —  cases.  R  =  rate. 


Chicken-pox. 


Age-groups. 

Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

C 

R 

C 

R 

C 

R 

C 

R 

C 

R 

C 

R 

C 

R 

Under  1  year 

98 

660 

85 

660 

51 

773 

34 

541 

13 

661 

6 

627 

7 

692 

1  to  4  years 

484 

888 

426 

886 

220 

911 

206 

860 

58 

905 

20 

642 

38 

1154 

0  to  4  years 

582 

839 

511 

838 

271 

881 

240 

554 

71 

848 

26 

639 

45 

1045 

5  to  9  years 

1118 

1734 

1053 

1866 

540 

1889 

513 

1843 

65 

806 

42 

1088 

23 

547 

0  to  9  years 

1700 

1270 

1564 

1332 

811 

1367 

753 

1297 

136 

827 

68 

857 

68 

799 

10  to  19  years 

186 

150 

165 

153 

75 

142 

90 

164 

21 

132 

9 

127 

12 

135 

20  to  29  years 

30 

21 

19 

16 

13 

22 

6 

10 

11 

43 

6 

49 

5 

37 

30  to  39  years 

16 

13 

11 

11 

6 

12 

5 

10 

5 

23 

5 

45 

•  •  • 

«  •  •  • 

40  to  49  years 

5 

5 

3 

4 

2 

5 

1 

3 

2 

13 

1 

12 

1 

14 

50  to  59  years 

60  to  69  years 

1 

3 

1 

3 

1 

7 

70  to  79  years 
80  years  and 

over  . 

Total  . . 

1938 

264 

1763 

282 

908 

294 

855 

270 

175 

161 

89 

167 

86 

155 

Age-groups. 

Mumps. 

Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

C 

R 

C 

R 

C 

R 

C 

R 

C 

R 

C 

R 

C 

R 

Under  1  year . 

2 

13 

2 

16 

2 

30 

1  to  4  years . 

97 

178 

79 

164 

49 

203 

30 

125 

18 

281 

11 

353 

7 

213 

0  to  4  years . 

99 

143 

81 

133 

51 

166 

30 

69 

18 

215 

11 

270 

7 

163 

5  to  9  years . 

476 

738 

438 

776 

262 

917 

176 

632 

38 

471 

20 

518 

18 

428 

0  to  9  years . 

575 

430 

519 

442 

313 

528 

206 

355 

56 

341 

31 

391 

25 

294 

10  to  19  years . 

175 

141 

128 

119 

69 

131 

59 

107 

47 

295 

22 

311 

25 

281 

20  to  29  years . 

38 

26 

29 

24 

16 

27 

13 

22 

9 

35 

5 

41 

4 

29 

30  to  39  years . 

19 

16 

17 

17 

10 

20 

7 

14 

2 

9 

•  •  • 

•  •  • 

2 

19 

40  to  49  years . 

1 

1 

1 

1 

1 

3 

50  to  59  years . 

2 

3 

2 

4 

•  •  • 

•  •  • 

2 

7 

60  to  69  years . 

1 

3 

1 

3 

•  •  • 

•  •  • 

1 

6 

70  to  79  years . 

1 

7 

1 

8 

•  •  • 

•  •  • 

1 

13 

80  years  and  over.. .. 

Total  . 

812 

111 

698 

112 

409 

133 

289 

91 

114 

105 

58 

109 

56 

101 

years,  with  rates  somewhat  higher  for  negroes  than  for  whites,  the  incidence 
was  again  higher  in  whites  among  males  and  in  negroes  among  females.  The 
consequence  is  that  for  the  age  period  0  to  4  years  morbidity  was  practically 


FEBRILE  DISEASES 


299 


the  same  for  whites  and  negroes,  among  whites  considerably  higher  for  males 
than  for  females,  and  among  negroes  for  females  than  for  males.  In  the  age- 
group  5  to  9  years,  morbidity  among  whites  was  more  than  double  that  among 
negroes,  on  about  the  same  level  for  the  twro  sexes  in  whites,  but  twice  as  great 
for  males  as  for  females  in  negroes.  As  a  net  result  in  the  first  decade  of  life, 
in  which  the  overwhelming  majority  of  the  cases  occurred,  the  rate  of  incidence 
was  greater  in  whites  than  in  negroes  by  about  one-fourth  and  somewhat  greater 
in  males  than  in  females  of  both  races. 

SCARLET  FEVER. 

The  annals  of  Baltimore  do  not  mention  the  occurrence  of  scarlet  fever  in 
the  eighteenth  century,  and,  if  it  appeared  at  all,  it  was  probably  in  a  form  so 


Graph  13  (from  table  34).  Annual  crude  mortality-rates  from  scarlet  fever 

and  measles,  from  1812  to  1920,  inclusive. 

mild  that  few  or  no  deaths  were  attributable  to  it.  However,  as  in  those  times, 
and  indeed  until  well  after  the  middle  of  the  nineteenth  century,  it  was  included 
among  that  group  of  diseases  generally  regarded  as  necessary  afflictions  of  the 
human  race,  inevitable,  uncontrollable,  and,  therefore,  except  when  present  in 
the  form  of  severe  epidemic  visitation,  it  would  not,  unless  by  chance,  have 
found  space  in  local  chronicles.  That  the  disease  was  imported  repeatedly  from 
Europe  and  passed  at  quarantine  there  is  no  doubt.  As  late  as  1895,  cases  were 
often  sent  in  large  numbers  from  immigrant  ships  to  the  University  of  Mary¬ 
land  and  other  hospitals,  where  provisions  for  isolation  were  primitive  in  the 
extreme.  It  is  probable  that,  between  1830  and  1900,  due  to  classification  under 
dropsy,  nephritis,  middle-ear  disease,  meningitis,  and  even  diphtheria,  and 
the  rubrics  for  other  complications,  the  number  of  deaths  from  scarlet  fever  was 
actually  larger  than  officially  recorded.  The  course  of  the  curve  for  the  annual 
mortality  for  the  whole  period  (table  34,  graph  13)  is  marked  by  wide  fluctua- 
20 


300  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

tions,  which  are  in  general  of  two  general  types.  Fluctuations  of  the  first  type 
depend  upon  differences  in  the  general  level  of  the  rates  over  comparatively 
long  series  of  years  and  represent  true  waves  of  high  or  low  mortality.  Three 
such  waves  stand  out  until  distinctness. 

The  first  wave,  characterized  by  very  low  mortality,  covers  approximately 
the  second  and  third  decades  of  the  nineteenth  century,  when,  in  fatal  form 
at  least,  scarlet  fever  was  rare  in  Baltimore.  Between  1811  and  1829  there  were 
but  13  recorded  deaths.  The  first  was  in  1814,  and  then  after  an  interval  of 
5  years  there  were  4  in  1820  and  3  in  1821.  With  1  death  in  1823,  and  3  in 
1825,  4  years  elapsed  before  the  single  fatality  in  1829.  As  judged  by  recorded 
fatalities  during  this  period,  scarlet  fever  occurred  only  sporadically;  if 
endemically  established  the  disease  was  extremely  mild.  Quite  different  was 
its  course  after  1829.  Since  this  date,  in  every  year  scarlet  fever  has  been 
credited  with  deaths,  and  probably  at  no  time  has  the  city  been  entirely  free 
from  cases. 

After  the  sudden  outbreak  in  1830,  with  a  death  rate  of  172,  the  disease 
entered  on  a  long  wave  of  high  mortality,  which,  though  broken  here  and  there 
by  recessions,  lasted  until  1885.  In  many  of  these  55  years  the  disease  was  a 
veritable  scourge.  Years  of  exceptionally  high  fatality  were  1844,  1845,  1853, 
1858,  1862,  and  1871,  when  the  rates  were  270,  204,  263,  203,  263,  255,  and  224, 
respectively.  As  late  as  1875  and  1876  the  rates  were  as  high  as  in  1830  and 
1831.  After  1880  the  rate  did  not  surpass  100. 

The  third  wave,  which  embraces  the  period  since  1885,  is  characterized  by 
lower  and  gradually  declining  rates.  During  this  time  the  highest  rates  attained 
were  57  in  1892,  29  in  1891,  and  27  in  1904.  Rates  as  low  as  2  were  recorded 
in  1901,  1917,  and  1920,  and  in  1918  the  rate  was  1.  Since  1905,  scarlet  fever 
in  Baltimore  has  almost  lost  its  lethal  force,  which  now  exhibits  a  strong 
tendency  to  decline  to  the  level  obtaining  previous  to  1830. 

The  second  type  of  fluctuation  in  the  annual  rates  is  dependent  upon  a  quite 
different  characteristic,  namely,  the  frequent  occurrence  of  minor  epidemic 
waves  extending  over  2  or  3  years  and  followed  by  from  one  to  several  years  of 
remission,  or,  even  in  some  periods,  of  complete  intermission.  These  minor 
waves  recur  constantly,  though  not  always  at  equal  intervals,  whether  the 
general  level  of  mortality  be  low  or  high,  and  evidently  reflect  inherent  charac¬ 
ters  of  the  disease. 

A  much  clearer  picture  of  the  course  of  scarlet  fever  is  given  by  the  curve  of 
the  mortality-rates  as  averaged  for  5-year  periods  (table  43,  graph  14).  With 
rates  of  1  for  the  periods  ending  in  1815  and  1820  and  of  2  for  that  ending 
in  1825,  the  rates  for  the  period  ending  in  1830  jumped  to  35,  owing  to  the 
sudden  outbreak  of  the  disease  in  this  year.  From  1835,  the  curve  of  the  aver¬ 
aged  rates,  except  for  slight  recessions  in  1836-1840  and  1851-1855,  rose 
steadily  to  151  in  1856-1860.  This  represents  the  peak  of  the  mortality  of 
this  disease.  Falling  during  the  next  10  years  the  averaged  rate  was  62  in 
1866-1870.  Reacting  from  this,  the  rates  moved  upward  during  10  years  to 
119  in  1876-1880.  This  was  followed  by  a  fall  in  the  rates  to  50  in  1881-1885 
and  to  11  in  1886-1890.  From  this  low  level  there  was  a  reaction  to  25  in  1891- 
1895,  but  by  1896-1900  the  rate  had  fallen  to  7.  For  the  succeeding  5  years 
this  rate  rose  to  12,  only  to  fall  to  7  in  1906-1910,  6  in  1911-1915,  and  3  in 
1916-1920. 


FEBRILE  DISEASES 


301 


Table  43. — Average  rate  of  death  by  5-  and  10-ycar  -periods  from  total  acute  exanthema¬ 
tous  diseases,  from  1812  to  1020,  inclusive. 


Periods. 

Small-pox. 

Varicella. 

Scarlet 

fever. 

Measles. 

Influenza. 

Total  acute 
exan¬ 
thematous 
diseases. 

By  5-vear 
periods. 

By  10-year 
periods. 

By  5-year 

periods. 

By  10-year 

periods. 

By  5-year 

periods. 

By  10-year 

periods. 

By  5-year 

periods. 

By  10-vear 

periods. 

By  5-year 

periods. 

Bv  10- year 

periods. 

By  5-year 

periods. 

By  10-year 

periods. 

1812-15  . 

46 

•  •  • 

1 

24 

•  •  • 

13 

•  •  • 

83 

1816-20  . 

2 

21 

1 

1 

45 

35 

1 

6 

48 

64 

1821-25  . 

48 

•  •  • 

2 

•  •  • 

62 

•  •  • 

•  •  • 

•  •  • 

132 

•  •  • 

1826-30  . 

4 

26 

35 

18 

14 

38 

•  •  • 

•  •  • 

53 

83 

1831-35  . 

44 

•  •  • 

101 

•  •  • 

25 

•  •  • 

32 

•  •  • 

202 

•  •  • 

1836-40  . 

25 

35 

2 

1 

86 

93 

42 

33 

•  •  • 

16 

154 

178 

1841-45  . 

16 

•  •  • 

•  •  • 

119 

•  •  • 

21 

•  •  • 

1 

•  •  • 

157 

•  •  • 

1846-50  . 

38 

27 

1 

140 

129 

31 

26 

1 

1 

210 

183 

1851-55  . 

29 

•  •  • 

1 

135 

•  •  • 

53 

•  •  • 

•  •  • 

218 

•  •  • 

1856-60  . 

41 

35 

1 

1 

151 

143 

41 

47 

•  •  • 

233 

225 

1861-65  . 

63 

•  •  • 

1 

122 

•  •  • 

29 

•  •  • 

•  •  • 

215 

•  •  • 

1866-70  . 

1 

32 

•  •  • 

1 

62 

92 

44 

36 

•  •  • 

107 

161 

1871-75  . 

105 

•  •  • 

1 

112 

•  •  • 

30 

•  •  • 

•  •  • 

248 

•  90 

1876-80  . 

•  •  • 

53 

119 

116 

15 

22 

•  •  • 

133 

191 

1881-85  . 

67 

•  •  • 

50 

•  •  • 

29 

•  •  • 

•  •  • 

147 

... 

1886-90  . 

34 

11 

31 

35 

32 

1 

•  •  • 

47 

97 

1891-95  . 

•  •  • 

25 

•  •  • 

11 

•  •  • 

36 

•  •  • 

72 

•  •  • 

1896-1900  . 

•  •  • 

7 

16 

5 

8 

21 

29 

33 

53 

1901-05  . 

•  •  • 

12 

•  •  • 

7 

•  •  • 

17 

•  •  • 

37 

•  •  • 

1906-10  . 

•  •  • 

7 

9 

6 

7 

17 

17 

31 

34 

1911-15  . 

•  •  • 

6 

•  •  • 

8 

•  •  • 

13 

•  •  • 

27 

•  •  • 

1916-20  . 

•  •  • 

3 

4 

7 

7 

84 

48 

94 

60 

Graph  14  (from  table  43).  Crude  mortality-rates  from  scarlet  fever  and 
measles,  averaged  by  5-year  periods,  from  1812  to  1920,  inclusive 


302  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

Owing  to  the  very  great  variation  in  the  annual  mortality  rates,  the  rates 
as  averaged  for  10-years  periods  (table  43,  graph  15)  give  perhaps  an  even 
more  correct  picture  of  the  course  of  the  lethal  force  of  this  disease.  As  a 
result  of  the  greater  smoothing,  the  progress  of  the  curve  of  the  rates  is 
unbrokenly  upward  to  1851-1860,  with  a  rate  of  143,  and  from  this  point,  but 
for  a  slight  reaction  in  1871-1880,  the  course  of  the  curve  is  continuously 
downward.  The  rates  for  the  last  four  decennia  were  31,  16,  9,  and  4. 

From  this  analysis  it  is  clear  that  the  lethal  force  of  scarlet  fever,  negligible 
before  1830,  gained  continuously  in  vigor  for  three  decades  and  reached  its 
zenith  in  that  ending  in  1860,  and  since  this  date  it  has  gradually  and  almost 


Graph  15  (from  table  43).  Crude  mortality-rates  from  scarlet  fever  and 
measles,  averaged  by  10-year  periods,  from  1812  to  1920,  inclusive. 


uninterruptedly  lost  in  strength,  so  that  40  years  later  (1900)  it  had  returned 
to  the  level  of  1830.  By  1920  the  force  of  mortality  had  fallen  almost  to  the 
level  of  1820.  In  this  century  scarlet  fever,  considered  as  a  cause  of  mortality, 
had  risen  gradually  from  a  position  of  no  importance  to  become  for  many  years 
a  scourge  and  had  fallen  as  gradually  back  to  its  primary  position. 

As  at  least  90  per  cent  of  all  deaths  from  scarlet  fever  occur  in  individuals 
under  10  years  of  age  and  70  per  cent  in  those  under  5  years,  any  considerable 
changes  in  the  proportional  relations  of  these  age-groups  to  the  whole  popu¬ 
lation  must  have  exerted  an  important  influence  upon  the  course  of  its  mor¬ 
tality.  Between  1850  and  1920,  the  proportions  in  the  population  of  individuals 
in  age-group  0  to  4  years  declined  by  34  per  cent,  in  age-group  5  to  9  years 
by  26  per  cent,  and  in  age  group  0  to  9  years  by  31  per  cent,  and  it  may  be 
held  that  the  decline  in  the  scarlet-fever  death-rate  during  this  period  was 


FEBRILE  DISEASES 


303 


influenced  in  something  like  these  ratios  solely  by  shrinkage  in  these  propor¬ 
tions  in  the  relative  numbers  of  individuals  of  susceptible  age.  In  table  44  are 
given  the  rates  for  scarlet  fever  for  the  census  years  from  1830  to  1920,  inclu¬ 
sive,  calculated  on  the  basis  of  the  populations  under  10  years  of  age.  These 
rates,  within  somewhat  broad  limits,  specific  for  age  for  these  particular  years, 
demark  the  course  of  this  disease  with  much  greater  precision  than  do  the  crude 


Table  44. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants  under 
10  years  of  age,  from  scarlet  fever  and  measles,  for  the  decennia  1830  to  1920, 
inclusive. 

D  =  death.  R  =  rate. 


Year. 

Scarlet 

fever. 

Measles. 

Year. 

Scarlet 

fever. 

Measles. 

D 

R 

D 

R 

D 

R 

D 

R 

1830 . 

103 

495 

25 

120 

1880 . 

327 

440 

43 

58 

1840 . 

85 

318 

32 

120 

1890 . 

80 

87 

92 

101 

1850 . 

204 

457 

20 

45 

1900 . 

18 

18 

11 

11 

1860 . 

223 

397 

59 

105 

1910 . 

39 

38 

50 

49 

1870 . 

350 

537 

124 

190 

1920 . 

14 

10 

18 

13 

*  The  number  of  deaths  for  each  decenniom  is  a  3-year  average  of  that  obtaining 
in  the  decennial  year  and  in  those  years  immediately  preceding  and  following,  except  in 
1920  when  the  average  is  for  1919  and  1920  only. 


rates  already  considered.  It  is  obvious  that  the  picture  is  somewhat  distorted, 
for  had  the  calculations  been  extended  to  include  every  year,  rates  much 
higher  and  much  lower  than  those  obtained  would  have  been  found. 

Frick’s  analysis  of  the  deaths  from  scarlet  fever  in  Baltimore  in  1850  showed 
rates  per  10,000  inhabitants  of  13.8  for  whites  and  10.8  for  blacks;  the  lesser 
mortality  among  the  blacks  he  thought  was  probably  due  to  the  greater  diffi¬ 
culty  in  diagnosis  of  the  disease  in  this  race.  Classified  according  to  sex,  49 
per  cent  of  the  deaths  were  in  males  and  51  per  cent  were  in  females.  The 
proportion  of  the  225  deaths  he  ascribed  to  the  different  ages  is  shown  in 
table  45. 

Table  45. 


p.  c. 

Under  1  year .  10.9 

Between  1  and  2  years .  25.1 

Between  2  and  3  years .  20.0 

Between  3  and  4  years .  10.9 

Between  4  and  5  years .  9.1 

Between  5  and  10  years .  20.0 

Between  10  and  20  years .  9.7 

Over  20  years .  0.3 


The  death-rates  specific  for  age  are  given  in  table  36  (p.  284). 

In  one  of  the  few  allusions  in  the  annual  reports  to  the  specific  qualities  of 
scarlet  fever,  the  commissioner  of  health,  in  1870,  in  the  midst  of  the  period 
of  its  greatest  fatality,  remarked  that  it  attacked  persons  of  all  ages,  but  con¬ 
fined  its  ravages  principally  to  children  between  3  and  9  years,  and  that  few 
diseases  were  so  prevalent  among  children  and  none  more  fatal. 


304  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


Of  the  488  deaths  recorded  from  scarlet  fever  during  the  15-year  period 
1905-1919,  457  were  in  whites,  with  227  in  males  and  230  in  females,  and  31 
were  in  negroes,  with  15  in  males  and  16  in  females  (table  46).  While  there 
are  no  significant  differences  in  the  mortality  between  males  and  females 


Table  46. — Number  oj  deaths  and  rate  oj  death,  per  100,000  living  inhabitants,  from 
scarlet  fever  and  measles,  according  to  color  and  sex,  from  1905  to  1919,  inclusive. 

SCARLET  FEVER. 

D  =  death.  R  =  rate. 


Year. 

Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1905  . 

32 

6 

29 

6 

18 

8 

11 

5 

3 

4 

2 

5 

1 

2 

1906  . 

43 

8 

41 

9 

13 

6 

28 

12 

2 

2 

1 

3 

1 

2 

1907  . 

14 

3 

14 

3 

7 

3 

7 

3 

1908  . 

70 

13 

66 

14 

29 

13 

37 

15 

4 

5 

2 

5 

2 

4 

1909  . 

22 

4 

22 

5 

13 

6 

9 

4 

1910  . 

49 

9 

47 

10 

24 

10 

23 

9 

2 

2 

1 

2 

1 

2 

1911  . 

44 

8 

41 

8 

21 

9 

20 

8 

3 

3 

1 

2 

2 

4 

1912  . 

23 

4 

22 

4 

9 

4 

13 

5 

1 

1 

•  •  • 

•  •  • 

1 

2 

1913  . 

45 

8 

42 

8 

24 

10 

18 

7 

3 

3 

1 

2 

2 

4 

1914  . 

35 

6 

28 

6 

14 

6 

14 

6 

7 

7 

3 

7 

4 

8 

1915  . 

32 

5 

29 

6 

18 

7 

11 

4 

3 

3 

1 

2 

2 

4 

1916  . 

30 

5 

30 

6 

13 

5 

17 

7 

1917  . 

11 

2 

11 

2 

6 

2 

5 

2 

1918  . 

8 

1 

C 

1 

4 

2 

2 

1 

2 

2 

2 

4 

•  •  • 

•  •  • 

1919  . 

30 

4 

29 

5 

14 

5 

15 

5 

1 

1 

1 

2 

•  •  • 

•  •  • 

MEASLES. 


1905  . 

84 

16 

65 

14 

33 

7 

32 

14 

19 

23 

8 

21 

11 

24 

1906  . 

10 

2 

8 

2 

3 

1 

5 

2 

2 

2 

1 

3 

1 

O 

1907  . 

67 

12 

49 

10 

23 

10 

26 

11 

18 

21 

5 

13 

13 

27 

1908  . 

17 

3 

15 

3 

8 

3 

7 

3 

2 

2 

2 

5 

•  •  • 

•  •  • 

1909  . 

51 

9 

37 

7 

23 

10 

14 

6 

14 

16 

8 

20 

6 

12 

1910  . 

17 

3 

16 

3 

11 

5 

5 

2 

1 

1 

•  •  • 

•  •  • 

1 

2 

1911  . 

73 

13 

60 

12 

32 

13 

28 

11 

13 

14 

8 

19 

5 

10 

1912  . 

5 

1 

5 

1 

2 

1 

3 

1 

1913  . 

115 

19 

86 

17 

50 

20 

36 

14 

29 

31 

20 

47 

9 

18 

1914  . 

5 

1 

5 

1 

1 

4 

2 

1915  . 

17 

3 

13 

3 

5 

2 

8 

3 

4 

4 

2 

5 

2 

4 

1916  . 

34 

6 

29 

6 

17 

7 

12 

5 

5 

5 

3 

7 

2 

4 

1917  . 

51 

8 

40 

8 

20 

8 

20 

8 

11 

11 

6 

13 

5 

9 

1918  . 

75 

12 

62 

12 

29 

11 

33 

13 

13 

13 

4 

9 

9 

17 

1919  . 

7 

] 

7 

1 

6 

2 

1 

among  either  whites  or  blacks,  the  fatality  was  proportionally  nearly  three 
times  greater  in  the  white  than  in  the  negro  race,  the  number  of  deaths  standing 
in  the  ratio  of  15  to  1,  and  the  population  5.42  to  1,  repectively,  a  remarkably 
high  shift  in  favor  of  the  negro  since  1850.  It  is  unlikely  that  such  a  great 
difference  is  to  be  explained  entirely  by  greater  difficulty  in  diagnosis  in  the 
negro. 


FEBRILE  DISEASES 


305 


The  results  of  calculations  to  determine  the  influence  of  age,  sex,  and  color 
upon  the  mortality  of  scarlet  fever  in  1910  and  1920  are  shown  in  tables  47 
and  48.  Whereas  there  are  no  significant  differences  between  the  rates  for  all 
ages  in  males  and  females  of  the  white  and  colored  races,  the  total  white  rate  is 
over  four  times  as  great  as  that  for  negroes.  Owing  to  the  smallness  of  the 
number  of  deaths  and  the  differences  in  the  age-groupings,  direct  comparison 


Table  47. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from 
scarlet  fever  and  measles,  according  to  age,  color,  and  sex,  for  1910. 

SCARLET  FEVER. 


D  =  death.  R  =  rate. 


Age  period. 

Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Mal'e. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

Under  1  year . 

1 

10 

1 

11 

1 

22 

Between  1  and  2  years 

7 

73 

7 

83 

3 

68 

4 

98 

2  to  4  years . 

23 

72 

22 

79 

13 

92 

9 

65 

1 

24 

1 

50 

•  •  • 

•  •  • 

5  to  9  years . 

10 

20 

10 

23 

7 

32 

3 

14 

Under  10  years . 

41 

40 

40 

45 

24 

54 

16 

36 

1 

8 

1 

16 

•  •  • 

10  to  19  years . 

5 

5 

4 

4 

4 

9 

1 

7 

•  •  • 

•  •  • 

1 

13 

20  to  29  years . 

1 

1 

1 

1 

1 

2 

30  to  39  years . 

1 

1 

1 

J 

1 

3 

40  to  49  years . 

50  to  59  years . 

1 

2 

1 

3 

1 

5 

60  years  and  over.... 

Total  . 

49 

9 

47 

10 

24 

10 

23 

9 

2 

2 

1 

3 

1 

2 

MEASLES. 


Under  1  year . 

3 

29 

3 

34 

1 

22 

2 

45 

Between  1  and  2  years 

12 

125 

11 

130 

8 

182 

3 

73 

1 

89 

•  •  • 

•  •  • 

1 

175 

2  to  4  years . 

1 

31 

1 

4 

1 

7 

5  to  9  years . 

1 

2 

1 

2 

1 

5 

Under  10  years . 

10  to  19  years . 

20  to  29  years . 

30  to  39  years . 

17 

17 

16 

18 

11 

25 

5 

11 

1 

8 

•  •  • 

•  •  • 

1 

15 

40  to  49  years . 

50  to  59  years . 

60  years  and  over.... 

Total  . 

17 

3 

16 

3 

11 

5 

5 

2 

1 

1 

•  •  • 

•  •  • 

1 

2 

of  the  relative  influence  of  age  in  this  year  and  in  1850,  as  shown  in  the  rates 
described  from  Frick’s  figures,  is  difficult.  In  both  tables  the  great  bulk  of  the 
deaths  occur  under  the  tenth  year. 

Though  legally  reportable  since  1882,  there  are  no  records  of  reported  cases 
of  scarlet  fever  before  1893,  and  it  is  only  since  1897  that  case  reporting  has 
approached  accuracy.  The  absolute  figures  of  reported  cases  by  months  and 
years  and  the  appropriate  rates  are  presented  in  table  49.  These  monthly 


306  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

annual  and  the  annual  morbidity-rates  from  1897  to  1920  may  be  compared 
with  similar  rates  for  mortality  given  in  table  50.  The  course  of  the  curves 
for  the  morbidity-  and  mortality-rates  during  this  period  corresponds  very 
closely.  Such  differences  as  exist  are  not  very  significant  and  are,  in  large  part 
at  least,  explained  by  the  lag  of  deaths  behind  reported  cases.  The  degree  of 
difference,  that  is,  the  variation  in  the  relative  heights  of  the  two  curves  in 


Table  48. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from 
scarlet  fever  and  measles,  according  to  age,  color,  and  sex,  for  1920. 

SCARLET  FEVER. 


D  =  death.  R  =  rate. 


Total. 

White. 

Colored. 

Age-groups. 

Total. 

Male. 

Fern. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

R 

D 

R 

D 

R 

D 

R 

Under  1  year . 

1  to  4  years . 

0  to  4  years . 

8 

12 

8 

13 

4 

13 

4 

9 

5  to  9  years . 

1 

2 

1 

2 

1 

3 

0  to  9  years . 

9 

7 

9 

8 

5 

8 

4 

7 

10  to  19  years . 

1 

1 

1 

1 

•  •  • 

•  •  • 

1 

2 

20  to  29  years . 

2 

1 

2 

2 

•  •  • 

•  •  • 

2 

3 

30  to  39  years . 

1 

1 

1 

1 

1 

2 

40  to  49  years . 

50  to  59  years . 

60  to  69  years . 

70  to  79  years . 

80  years  and  over .... 

Total  . 

13 

2 

13 

2 

6 

2 

7 

2 

MEASLES. 


Under  1 

year . 

12 

81 

10 

78 

6 

91 

4 

64 

2 

101 

1 

104 

1 

99 

1  to 

4 

years . 

34 

62 

30 

62 

17 

70 

13 

54 

4 

62 

2 

64 

2 

61 

0  to 

4 

years . 

46 

66 

40 

66 

23 

75 

17 

39 

6 

72 

3 

74 

3 

70 

5  to 

9 

years . 

3 

5 

3 

5 

2 

7 

1 

4 

0  to 

9 

years . 

49 

37 

43 

37 

25 

42 

18 

31 

6 

36 

3 

38 

3 

35 

10  to 

19 

years . 

20  to 

29 

years . 

30  to 

39 

years . 

40  to 

49 

years . 

50  to 

59 

years . 

60  to 

69 

years . 

70  to 

79 

years . 

80  years 

and  over. . . . 

Total  . 

49 

7 

43 

7 

25 

1 

8 

18 

6 

6 

6 

3 

6 

3 

5 

corresponding  years,  is  often  marked,  and  reflects  the  considerable  variation  in 
the  annual  case-fatality  rates. 

Referring  to  table  49,  it  will  be  noted  that,  beginning  in  1897  with  a  rate 
of  212  the  morbidity-rates  declined  during  the  succeeding  4  years  to  76  in  1901. 
Rising  then  to  92  in  1902  and  abruptly  to  232  in  1903  and  229  in  1904,  they 


Table  49. — Morbidity  by  months  and  years  and  the  monthly  annual  and  annual  rates  of  morbidity,  per  100,000  living  inhabitants,  from  scarlet  fever, 

from  1897  to  1920,  inclusive. 


FEBRILE  DISEASES 


307 


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310  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

fell  by  gradual  stages  to  79  in  1907.  Rebounding  sharply  to  243  in  1908,  the 
course  heretofore  pursued  was  abandoned,  and  the  rate  dropped  abruptly  to 
81  in  1909.  The  course  of  the  disease,  as  judged  by  its  behavior  in  calendar 
years,  was  modified  again,  when  the  rate  rose  to  205  in  1910,  and  fell  the  next 
year  to  193,  and  in  1912  to  128.  After  rising  to  193  in  1913,  and  falling  to 
135  in  1914,  the  rate  ascended  to  211  in  1915.  Again  there  was  a  change  in 
the  course  of  the  disease.  Instead  of  ascending  and  declining  in  alternate  years, 
as  had  been  the  habit  since  1912,  the  rate  now  dropped  abruptly  for  three  suc¬ 
cessive  years,  and  in  1918  reached  the  unusually  low  level  of  59,  the  lowest 
recorded  morbidity  incidence.  In  1919,  with  a  suddenly  renewed  vigor  of 
attack,  the  rate  rose  to  the  remarkably  high  level  of  535.  The  considerable 
drop  in  1920  to  170  left  the  r.°te  appreciably  higher  than  the  average. 

When  the  course  of  morbidity  during  these  24  years  is  measured  by  rates 
averaged  for  5-year  periods,  it  is  seen  (table  49)  that  from  the  comparatively 
low  level  of  124  for  1897-1900  (4  years)  it  increased  to  149  for  1901-1905, 
remained  stationary  at  143  for  1906-1910,  and  rose  considerably  to  172  for 
1911-1915  and  to  212  for  1916-1920.  During  this  period  the  mortality-rates 
averaged  for  the  same  periods  pursued  quite  a  different  course.  Rising  out  of 
all  proportion  to  the  rise  in  the  morbidity-rates  from  7  for  the  first  period  to 
12  for  the  second,  they  fell  to  7  for  the  third  period,  when  the  morbidity-rates 
were  stationary,  and  during  the  remaining  periods  declined  continuously  to  3 
in  1920,  in  the  face  of  constantly  rising  morbidity-rates.  The  case  fatality 
rates  similarly  averaged  fell  from  6  per  cent  to  2  per  cent.  Thus  the  striking 
spectacle  is  presented  of  a  rise  in  the  incidence  of  attack  by  58  per  cent  and 
declines  in  the  death-rate  by  57  per  cent  and  in  the  case-fatality  rate  by 
67  per  cent. 

For  the  sake  of  comparison  it  will  be  profitable  to  form  some  approximate 
estimate  of  what,  on  the  basis  of  recent  case-fatality  experience,  the  morbidity 
would  have  been  when  the  mortality  was  much  higher.  For  this  purpose,  as 
examples  of  the  highest  and  lowest  average  case-fatality  rates  of  recent  experi¬ 
ence,  those  of  1901-1905,  7  per  cent,  and  those  of  1916-1920,  2  per  cent,  will 
be  taken.  As  sample  years  with  high  death-rates,  1850  and  1871,  when  the 
deaths  numbered  225  and  625,  and  the  population  numbered  163,930  and 
278,932,  respectively,  will  serve.  On  this  basis,  in  1850  the  higher  case  inci¬ 
dence  would  have  been  11,250,  or  a  morbidity-rate  of  6,863,  and  the  lower  3,214, 
or  a  morbidity-rate  of  1,961;  in  1871,  the  higher  case  incidence  would  have 
been  31,250  with  a  morbidity-rate  of  11,203,  and  the  lower,  8,929,  or  a  mor¬ 
bidity-rate  of  3,201.  The  mortality-rates  were  137  in  1850  and  224  in  1871. 
Expressed  otherwise,  calculated  on  the  basis  of  the  population  under  10  years 
of  age,  in  1850  the  higher  case  incidence  would  have  equaled  1  in  every  4  and 
the  lower  1  in  every  13 ;  in  1871,  the  former  would  have  equaled  1  in  every  2 
and  the  latter  1  in  every  7.  When  these  figures  are  compared  with  those  of 
recent  experience,  and  particularly  with  that  of  1919,  when  the  morbidity-rate 
was  535,  the  mortality-rate  was  2,  and  the  percentage  of  case-fatality  was 
0.78,  the  actual  occurrence  of  any  such  rates  of  incidence  of  scarlet  fever  as 
those  deduced  for  1850  and  1871  seems  impossible.  Taking  into  account  the 
fact  that  for  more  than  20  years  before  1871  very  high  mortality-rates  had 
been  in  almost  constant  vogue,  on  any  low  percentage  of  case-fatality  there 


FEBRILE  DISEASES 


311 


could  hardly  have  been  a  sufficient  number  of  susceptibles  in  the  population  to 
permit  such  a  high  case  incidence  for  a  disease  in  which  one  attack  as  a  rule 
confers  lasting  immunity.  Therefore,  the  conclusion  is  unavoidable  that  during 
the  period  of  high  mortality  the  morbidity-rate  must  have  been  relatively  low 


Table  51. — Number  of  cases  and  the  rate  of  morbidity,  per  100,000  living  inhabitants  in 
1920,  from  scarlet  fever  and  measles,  according  to  age,  color,  and  sex,  for  1921. 

SCARLET  FEVER. 


O  =  cases.  R  =  rate. 


Age-groups. 

Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

C 

R 

C 

R 

C 

R 

1 

C 

R 

C 

R 

C 

R 

C 

R 

Under  1  year . 

7 

47 

6 

47 

2 

30 

4 

64 

1 

51 

•  •  • 

•  •  • 

1 

99 

1  to  4  years . 

238 

437 

233 

484 

119 

493 

114 

476 

5 

78 

3 

96 

2 

61 

0  to  4  years . 

245 

353 

239 

392 

121 

394 

118 

272 

6 

72 

3 

74 

3 

70 

5  to  9  years . 

481 

746 

459 

813 

210 

735 

249 

894 

22 

273 

14 

363 

8 

190 

0  to  9  years . 

726 

542 

698 

595 

331 

558 

367 

632 

28 

170 

17 

214 

11 

129 

10  to  19  years . 

261 

211 

249 

231 

108 

204 

141 

257 

12 

75 

10 

141 

2 

22 

20  to  29  years . 

64 

44 

62 

52 

27 

46 

35 

58 

2 

8 

1 

8 

1 

7 

30  to  39  years . 

11 

9 

11 

11 

7 

14 

4 

8 

40  to  49  years . 

2 

2 

2 

3 

•  •  • 

•  •  • 

2 

5 

50  to  59  years . 

1 

2 

1 

2 

•  •  • 

•  •  • 

1 

4 

Total  . 

1065 

145 

1023 

164 

473 

153 

550 

174 

42 

39 

28 

53 

14 

25 

MEASLES. 


Age-groups. 

Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

C 

R 

C 

R 

C 

R 

C 

R 

C 

R 

C 

R 

C 

R 

Under  1  year. 

75 

505 

72 

559 

33 

500 

39 

621 

3 

152 

1 

104 

2 

198 

1  to  4  years. 

813 

1492 

800 

1663 

425 

1760 

375 

1566 

13 

203 

7 

225 

6 

182 

0  to  4  years. 

888 

1280 

872 

1430 

458 

1490 

414 

955 

16 

191 

8 

197 

8 

186 

5  to  9  years. 

1164 

1805 

1132 

2006 

571 

1998 

561 

2015 

32 

397 

12 

311 

20 

475 

0  to  9  years. 

2052 

1533 

2004 

1707 

1029 

1734 

975 

1679 

48 

292 

20 

252 

28 

329 

10  to  19  years. 

141 

114 

137 

127 

69 

131 

68 

124 

4 

25 

•  •  • 

•  •  • 

4 

45 

20  to  29  years. 

29 

20 

27 

23 

13 

22 

14 

23 

2 

8 

1 

8 

1 

7 

30  to  39  years. 

9 

7 

8 

8 

5 

10 

3 

6 

1 

5 

•  •  • 

•  •  • 

1 

9 

40  to  49  years. 

2 

2 

2 

3 

1 

3 

1 

3 

50  to  59  years. 

3 

5 

3 

5 

2 

7 

1 

4 

Xot^l  •  •  •  • 

2236 

305 

2181 

349 

1119 

363 

106 

2335 

55 

51 

21 

39 

34 

61 

and  the  case-fatality  comparatively  high,  as  compared  with  the  experience  of 
the  last  20  years,  when  the  reverse  has  held.  It  seems  evident,  therefore,  that 
as  the  lethal  force  of  scarlet  fever  has  diminished,  its  invasive  capacity  has 
increased. 

Morbidity-rates  specific  for  color,  sex,  and  age,  in  1921  are  given  in  table  51. 
Two-thirds  of  the  reported  cases  were  in  individuals  under  the  tenth  year,  and 


312  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

of  the  remainder  comparatively  few  were  above  the  twentieth  year  of  age. 
As  with  measles,  the  attack-rate  was  notably  higher  among  whites  than  among 
negroes  in  every  age-group,  and  in  both  races  the  incidence  was  greater  during 
the  second  than  during  the  first  five  years  of  life. 

From  a  study  of  the  monthly  annual  mortality-rates  (table  49)  and  mor¬ 
bidity-rates  (table  50)  it  is  clear  that,  as  a  general  rule,  the  incidence  and 
fatality  of  scarlet  fever  are  lowest  in  the  warm  months  and  highest  in  the  colder 
months.  In  typical  years  these  rates  are  lowest  in  June,  July,  August,  and 
September,  gradually  increase  through  October,  November,  December,  and 
January,  to  a  peak  reached  in  January  or  February,  and  then  as  gradually 
decline.  The  ascent  and  the  decline  in  the  rates  are  by  no  means  always  so 
gradual  and  uninterrupted.  While  the  course  of  the  curves  for  morbidity 


Table  52. — Maximum  and  minimum  incidence  of  mortality  and  morbidity  from  scarlet 
fever,  by  months,  from  1856  to  1899,  inclusive,  and  from  1897  to  1920,  inclusive, 
respectively ,  and  the  percentage  of  each  to  the  total  number  of  years. 


Months. 

Months  in  34 
years  in  which 
maximum 
mortality-rate 
obtains. 

Months  in  34 
years  in  which 
minimum 
mortality-rate 
obtains. 

Months  in  24 
years  in  which 
maximum 
morbidity-rate 
obtains. 

Months  in  24 
years  in  which 
minimum 
morbidity-rate 
obtains. 

No. 

Percentage 
to  total  years. 

No. 

Percentage 
to  total  years. 

No. 

Percentage 
to  total  years. 

No. 

Percentage 
to  total  years. 

Jan . 

9 

26 

•  •  • 

9 

38 

•  •  • 

•  •  • 

Feb . 

4 

12 

2 

6 

4 

17 

1 

4 

Mar . 

2 

6 

4 

12 

1 

4 

•  •  • 

•  •  • 

Apr . 

1 

3 

2 

6 

4 

17 

•  •  • 

•  •  • 

May  . 

•  •  • 

•  •  • 

•  •  • 

•  •  • 

•  •  • 

•  •  • 

•  •  • 

•  •  • 

June  . 

3 

9 

1 

3 

•  •  • 

•  •  • 

1 

4 

J  uly  . 

•  •  • 

•  •  • 

3 

9 

•  •  • 

•  •  • 

8 

33 

Aug . 

•  •  • 

•  •  • 

7 

21 

•  •  • 

•  •  • 

8 

33 

Sept . 

1 

3 

5 

15 

1 

4 

5 

21 

Oct . 

1 

3 

7 

21 

1 

4 

•  •  • 

•  •  • 

Nov . 

2 

6 

2 

6 

•  •  • 

•  •  • 

•  •  • 

•  •  • 

Dec . 

11 

32 

1 

3 

4 

17 

1 

4 

Total  . . 

34 

100 

34 

100 

24 

100 

24 

100 

and  mortality  usually  follow  each  other  closely,  the  highest  mortality  by  no 
means  always  occurred  in  the  months  of  highest  morbidity. 

Maximum  and  minimum  incidence  of  mortality  and  morbidity  by  months 
as  experienced  in  percentages  of  occurrence  in  series  of  years  is  shown  in 
table  52. 

Maximum  monthly  mortality-rates  occurred  in  percentages  of  the  34  years, 
1856  to  1899,  as  follows :  December  32,  January  26,  February  12,  June  9, 
March  and  November,  each,  6,  April,  September,  and  October,  each,  3.  Mini¬ 
mum  monthly  rates  similarly  expressed  were  distributed,  August  and  October, 
each,  21,  September  15,  March  12,  July  9,  February,  April,  and  November,  each, 
6,  June  and  December,  each,  3.  Maximum  rates  in  no  year  fell  in  May,  July, 
or  August,  and  May  was  the  only  month  in  which  minimum  rates  have  never 
occurred.  Somewhat  different  was  the  relation  of  high  and  low  morbidity 
occurrence  in  relation  to  months  for  the  24  years  from  1897  to  1920. 


FEBRILE  DISEASES 


313 


The  percentage  of  occurrence  of  maximum  morbidity-rates  by  months  was : 
January  38,  February,  April,  and  December,  each,  17,  and  March,  September, 
and  October,  each,  4.  For  minimum  morbidity-rates,  the  percentage  of  occur¬ 
rence  by  months  was:  July  and  August,  each,  33,  September  21,  February, 
June,  and  December,  each,  4.  The  highest  monthly  annual  morbidity-rates 
never  occurred  in  May,  June,  July,  August,  or  November,  and  similarly  the 
lowest  rates  were  never  met  with  in  January,  March,  April,  May,  October,  or 
November. 

As  after  1899,  in  many  years,  there  were  often  no  deaths  in  two  or  more 
months,  it  is  not  possible  to  compare  the  distribution  of  maximum  and  mini¬ 
mum  monthly  annual  mortality-  and  morbidity-rates  for  the  same  series  of  * 
years.  As  the  effect  of  season  upon  mortality  may,  of  course,  depend  upon  other 
factors  besides  incidence  of  the  disease,  direct  comparison  of  the  results  obtained 
in  these  two  different  series  of  years  is  not  allowable.  However,  it  is  evident 
that,  on  the  whole,  since  1856  maximum  morbidity  and  mortality  of  scarlet 
fever  must  have  fallen  in  winter  and  spring  and  minimum  morbidity  and 
mortality  in  the  summer  and  fall  months. 

While,  unfortunately,  they  are  incomplete  in  many  important  details,  the  data 
presented  in  the  foregoing  pages  furnish  materials  of  exceptional  value  for 
the  elucidation  of  the  natural  history  of  scarlet  fever  over  a  period  of  110  years. 
The  more  salient  features  of  this  history  may  be  summarized  as  follows :  It  has 
not  only  been  responsible  for  more  deaths  than  any  other  member  of  this  group, 
but  it  has  been  one  of  the  most  important  single  causes  of  mortality.  It  was  only 
after  repeated  epidemic  invasions  that  the  disease  became  endemically  estab¬ 
lished.  From  a  disease  of  slight  incidence  and  probably  mild  fatality  in  the 
earlier  years  of  the  nineteenth  century,  there  was  a  gradual  increase  in  mor¬ 
tality-rates  to  a  high  peak  about  1860.  Without  the  interpolation  of  restrictive 
measures  in  any  form,  there  was  a  marked  decline  of  mortality  between  1860 
and  1870.  The  mortality-rates  ascended  to  a  second  high  peak  in  1880,  and, 
again  in  the  complete  absence  of  restrictive  measures,  declined  abruptly  during 
the  next  10  years,  and  gradually  thereafter  to  a  very  low  level  by  1900.  There 
was  a  continued,  though  relatively  slight,  decline  in  the  mortality-rates  during 
the  next  20  years,  in  association  with  the  use  of  restrictive  measures. 

But  a  hundred  years  of  laissez  faire  had  witnessed  the  ascent  of  this  disease 
from  a  comparatively  innocuous  to  one  of  the  most  fatal  of  affections,  followed 
by  a  descent  to  a  mortality-rate  of  almost  negligible  importance. 

During  the  last  20  and  probably  the  last  40 .years,  the  morbidity-rates  have 
increased  as  the  mortality-rates  have  declined ;  in  other  words,  the  capacity  of 
scarlet  fever  to  attack  the  population  has  increased  as  its  lethal  force  has  dimin¬ 
ished.  During  its  state  of  endemicity,  the  tendency  to  periodic  epidemic 
outbreaks  has  persisted. 

During  the  past  65  years,  very  much  the  same  seasonal  incidence  has  been 
preserved.  A  very  remarkable  change  has  occurred  in  the  ratio  of  mortality 
among  negroes  as  compared  with  whites.  In  1850  the  mortality-rate  for  the 
former  was  only  about  one-fourth  less  than  that  for  the  latter,  while  during 
the  past  15  years,  the  mortality  was  nearly  three  times  greater  among  whites 
than  among  negroes. 


314  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

Finally,  in  the  20  years  of  their  trial,  administrative  measures  directed  to 
control  the  spread  of  scarlet  fever  have  not  been  attended  by  any  discernible 
positive  influence  upon  morbidity. 

MEASLES. 

The  date  of  the  first  appearance  of  measles  in  Baltimore  is  not  recorded,  and 
no  direct  references  to  its  presence  occurred  before  1802.  The  inference  that 
it  was  an  epidemic  visitant  and  not  endemic  in  Baltimore  Town  in  the  eight¬ 
eenth  century  is  justified  by  certain  statements  of  Nathaniel  Potter  (60)  in 
a  paper  on  the  measles  epidemics  of  1802  and  1808.  From  Potter’s  statements 
it  is  clear  that  the  disease  appeared  only  in  epidemic  form  in  the  first  decade 
of  the  nineteenth  century,  and  the  figures  in  the  tables  of  interments  show  that, 
so  far  as  can  be  judged  by  recorded  fatalities,  this  disease  was  not  established 
endemically  until  about  1820.  Eef erring  in  his  paper  to  certain  deviations 
noted  in  the  characteristics  of  the  disease  in  1802  from  the  usual  course  of 
“  morbillous  fever,”  he  stated,  “  as  this  epidemic  disease  observes  nearly  equi¬ 
distant  periods  of  visitation,  appearing  about  once  in  6  years,  no  occasion  for 
further  observation  presented  itself  till  1808.”  The  epidemic  of  the  latter  year, 
according  to  Potter,  followed  the  spread  of  the  disease  across  the  counties  of 
Maryland  from  Kent  and  Sussex  Counties,  Delaware,  where  it  was  recognized 
early  in  January  1808.  By  the  middle  of  February  the  disease  had  invaded 
Caroline  County,  the  eastern  boundary  of  Maryland,  and  before  the  middle  of 
April  the  whole  peninsula  was  affected.  It  reached  Baltimore  the  middle  of 
May  and  continued  to  prevail  until  the  middle  of  June,  when  apparently  it 
died  out  completely. 

As  the  disease  had  been  present  in  Baltimore  in  1802,  Potter  surmised  that 
it  could  not  now  become  generally  epidemic  and  that  the  children  born  since 
the  last  epidemic  would  be  the  chief  sufferers.  On  the  contrary,  this  was  not 
the  case;  usually  only  the  older  children  and  often  only  one  in  a  family  of 
children,  who  had  not  been  previously  exposed,  contracted  the  disease.  Many 
adults  who  escaped  in  1802  were  affected  and  suffered  much  more  severely  than 
children.  In  the  epidemic  of  1808  the  disease  departed  from  the  usual  inflam¬ 
matory  type,  with  coryza,  conjunctivitis,  sore  throat,  pains  in  the  back  and 
limbs,  and  pulmonary  complications  so  characteristic,  but  was  marked,  almost 
invariably,  by  a  “  typhoid  state  ”  in  which  the  patient  lay  in  a  dull  stupor, 
insensible  to  every  passing  event,  unless  the  eyes  were  affected.  The  period  of 
fever  and  the  time  of  the  appearance  of  the  eruption  were  very  irregular.  Some 
patients  had  a  continued  fever  for  10  or  even  15  days  and  no  eruption.  In  some, 
the  eruption  appeared  on  the  third  or  fourth  day  and  in  others  not  until  the 
seventh,  tenth,  eleventh,  thirteenth,  or  even  the  fifteenth  day.  Some  individuals, 
after  convalescing  from  an  attack  of  continuous  fever  without  eruption,  were 
taken  sick  again  after  20  days  and  had  copious  eruption.  Two  persons  in  the 
same  house  were  seldom  attacked  simultaneously,  but  the  second  case  generally 
took  sick  on  the  twentieth  or  twenty-first  day  from  the  indisposition  of  the  first. 
Common  complications  were  hemorrhage  from  the  nose,  occurring  either  before 
the  onset  of  the  fever  or  at  a  time  of  the  eruption,  and  severe  inflammation  of 
the  cornea  or  even  the  whole  eye. 

It  may  be  said  that  measles  in  Baltimore  in  the  first  20  years  of  the  nine¬ 
teenth  century  behaved  as  it  now  does  in  village  and  rural  communities,  i.  e., 


FEBRILE  DISEASES 


315 


as  short-lived  epidemics  of  greater  or  less  severity,  followed  by  periods  in  which 
the  disease,  in  recognized  form  at  least,  entirely  disappears.  However,  the 
epidemic  of  1808  may  have  marked  the  period  of  the  permanent  residence  of 
the  disease  in  the  city,  for  the  absence  for  the  records  of  deaths  ascribed  to  it 
in  1811,  1812,  1814,  1817,  1818,  and  1820  does  not  absolutely  preclude  its 
presence  during  those  years,  and  the  considerable  death-rates  of  1813  and  1810 
may  mark  only  exacerbations  of  endemic  measles  and  not  necessarily  an  epi¬ 
demic  due  to  a  new  importation  of  the  disease.  Much  more  likely,  however, 
the  disease  died  out  completely  in  1808,  and  a  new  epidemic  invasion  began 
5  years  later,  in  1813,  probably  in  connection  with  the  mobilization  of  troops 
to  defend  the  city,  and  after  this  date  measles  settled  permanently  in  the  city. 

However  this  may  be,  after  the  outbreak  of  considerable  severity  in  1813 
(table  34,  graph  13)  and  that  of  moderate  severity  in  1815-1816,  there  came 
the  much  more  fatal  one  of  1819,  which  was  preceded  by  2  years  and  followed 
by  1  year  with  no  recorded  fatalities.  With  slight  fatalities  in  the  next  2  years 
(1821  and  1822),  the  city  experienced  the  most  fatal  measles  epidemic  of  any 
single  year  of  its  history  with  a  mortality-rate  of  268,  one  that  was  preceded 
by  2  years  of  low  rates  and  succeeded  by  5  years  of  descending  rates.  This 
irregularity  in  the  annual  mortality  rates  is  a  characteristic  retained  through¬ 
out  its  subsequent  history  in  Baltimore.  Its  course  is  marked  by  a  series  of 
peaks  separated  in  no  regular  order  by  periods  of  2,  3,  4,  or  even  5  years.  Years 
of  exceptionally  high  rates  were  as  follows:  1819,  209;  1823,  268;  1837,  129; 
1852,  181;  1857,  103;  1869,  85.  Years  of  moderately  high  rates  were:  1829, 
56;  1834,  78;  1842,  80;  1846,  78;  1854,  54;  1862,  68;  1864,  60;  1868,  75; 
1869,  85;  1884,  62;  1886,  53;  1890,  57.  Since  1893,  the  rate  has  never  been 
above  20.  But  though  the  rates  have  fallen  so  conspicuously  since  1890,  the 
tendency  of  the  annual  rates  to  describe  wide  fluctuations  has  never  been  wholly 
lost. 

The  curve  of  the  annual  rates  averaged  for  5-year  periods  (table  43,  graph 
14)  describes  a  remarkable  and,  in  some  ways,  characteristic  course.  Whether 
the  level  of  mortality  be  high  or  low,  the  curve  is  marked  by  a  succession  of 
peaks  and  depressions,  which  recur  with  unfailing  regularity.  Beginning  with 
a  rate  of  24  for  the  5-year  period  ending  in  1815,  the  rate  rose  to  45  in  1816- 
1820  and  to  62  in  1821-1825  and  fell  sharply  to  14  in  1826-1830.  Reacting 
in  1831-1835  to  25  and  in  1836-1840  to  42,  the  rate  fell  to  21  in  1844-1845. 
The  rate  then  rose  to  31  in  1846-1850  and  to  53  in  1851-1855,  fell  to  41  in 
1856-1860  and  to  29  in  1861-1865.  For  the  next  5-year  period  the  rise  was 
sharp  to  44,  and  the  succeeding  fall  was  gradual  to  30  in  1871-1875  and  to 
15  in  1876-1880.  The  rate  now  stood  at  the  level  of  50  years  before.  This 
gain  was  not  permanent,  however,  for  the  rate  rose  to  29  in  1881-1885  and  to 
35  in  1886-1890.  Falling  to  11  in  1891-1895  and  to  5  in  1896-1900,  instead 
of  following  its  usual  course,  it  fluctuated  between  6  to  8  during  the  next  20 
years. 

In  the  rates  averaged  for  10-year  periods  (table  43,  graph  15),  the  rate  rose 
from  35  in  1812-1820  to  38  in  1821-1830  and  then  fell  to  33  in  1831-1840 
and  to  26  in  1841-1850.  Rising  again  to  47  in  1851-1860,  it  fell  to  36  in  1861- 
1870  and  to  22  in  1871-1880.  Reacting  to  32  in  1881-1890,  the  rate  fell 
sharply  to  8  in  1891-1900,  and  but  slightly  to  7  in  1901-1910.  During  the 
last  10  years  it  remained  stationary. 

21 


316  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

It  is  clear,  therefore,  from  an  analysis  of  the  course  of  the  mortality-rates, 
that  the  lethal  force  of  measles  has  experienced  very  considerable  modifications 
during  the  108  years  under  review.  After  increasing  very  considerably  between 
1812  and  1825,  it  diminished  during  the  next  10  or  15  years  and  then  with 
renewed  vigor  rose  to  a  still  higher  level  between  1850  and  1860.  Then  after  a 
period  of  gradual  decline  covering  about  20  years,  between  1880  and  1890,  for 
a  third  time  it  regained  strength.  This  final  effort  was  short-lived  and  rela¬ 
tively  weak,  and  by  1895  the  lethal  force  of  this  disease  had  become  compara¬ 
tively  impotent.  During  the  past  25  years  the  mortality-rate  has  tended  to 
stabilize  around  an  unprecedently  low  level.  It  will  be  shown  later  that  in 
the  decennial  years  1910  and  1920  nearly  the  whole  of  the  mortality  from 
measles  was  confined  to  the  first  decade  of  life.  Assuming,  as  is  probably  not 
far  from  actual  occurrence,  that  this  held  constantly,  rates  calculated  for  the 
census  years  1830  to  1920,  inclusive,  on  the  basis  of  the  populations  under  the 
tenth  year  of  life,  and  thus  corrected  in  large  measure  for  changes  in  the  age 
distribution  of  the  population,  should  give  a  much  more  accurate  picture  of  the 
changes  in  the  lethal  force  of  the  disease.  Rates  specific  for  age  so  calculated 
are  given  in  table  44.  From  these  it  appears  that  the  course  of  mortality  of 
measles  in  this  period  was  characterized  by  four  distinct  waves,  with  the  peaks 
of  the  third  and  fourth  much  lower  than  that  of  the  second,  which  was  in  turn 
considerably  higher  than  the  highest  level  of  the  first.  It  is  clear  that  mortality 
attained  its  highest  level  about  1870,  and  that  since  that  date  it  has  declined 
sharply,  though  in  irregular  fashion,  to  a  comparatively  low  point. 

Data  for  morbidity  are  available  by  months  and  years  since  1897.  While 
case  reporting  has  never  been  complete,  the  figures  since  1900  are  fairly  repre¬ 
sentative.  The  considerable  increase  in  morbidity-rates  since  1905  (table  53), 
probably  represents  an  actual  increase  in  prevalence.  The  annual  morbidity- 
rates,  like  those  for  mortality  during  this  period,  are  marked  either  by  alternate 
years  of  high  and  low  levels  or  by  comparatively  high  rates  for  2  or  3  years 
in  series. 

The  annual  rates  for  morbidity  and  mortality  as  a  rule  rise  and  fall,  at 
least  in  the  same  direction,  though  by  no  means  always  in  proportion,  for  a 
heavy  case  incidence  is  not  by  any  means  always  associated  with  a  correspond- 
ingly  great  increase  in  the  number  of  deaths. 

The  case-fatality,  then,  it  will  be  observed  may  be  higher  or  lower  than  the 
average  with  either  a  high  or  low  morbidity-rate.  The  case-fatality  rate  varied 
from  0.63  per  cent  to  3.38  per  cent. 

From  the  monthly  annual  morbidity-  and  mortality-rates  (tables  53  and 
54),  it  is  seen  that,  with  few  exceptions,  the  incidence  and  mortality  of  measles 
have  been  lowest  in  July,  August,  September,  October,  and  November,  and 
highest  in  December,  January,  February,  March,  April,  May,  and  June.  This 
characteristic  distribution  of  the  disease  has  held  in  years  of  both  high  and 
low  incidence. 

The  influence  of  season  upon  the  morbidity  and  mortality  as  expressed  in  the 
months  in  which  maximum  and  minimum  monthly  annual  morbidity-rates 
fell,  from  1897  to  1920,  and  in  which  maximum  mortality-rates  occurred  from 
1856  to  1920,  is  shown  in  table  55.  Maximum  morbidity-rates  occurred  in 
percentages  of  the  total  of  24  years,  as  follows :  May  33,  April  25,  December  21, 


Table  53. — Morbidity  by  months  and  years  and  monthly  annual  and  annual  rates  of  morbidity,  per  100,000  living  inhabitants,  from  measles, 

from  1897  to  1920,  inclusive. 

O  =  cases.  R  =  rate. 


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(317) 


Table  54. — Number  of  deaths  by  months  and  years  and  monthly  annual  and  annual  rates  of  death,  per  100,000  living  inhabitants,  from  measles, 

from  1856  to  1920,  inclusive. 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


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320 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


March  13,  January  8.  The  months  of  occurrence  of  minimum  rates  similarly 
expressed  stood  in  order  as  follows:  September  38,  October  29,  August  17, 
January  13,  November  4.  It  is  very  clear  that  conditions  which  obtain  in  Sep¬ 
tember,  October,  August,  January,  and  November,  in  the  order  named,  are  least 
favorable,  and  those  which  obtain  in  May,  April,  December,  and  March  are 
most  favorable  to  the  incidence  of  this  disease.  It  will  be  observed  that  the 
maximum  and  minimum  rates  not  infrequently  fell  in  January.  The  highest 
incidence  in  no  year  fell  in  February,  June,  or  July.  The  percentage  of  months 
in  the  65  years  in  which  the  maximum  mortality  occurred  were  June  15,  April 
and  July  14,  March  11,  January,  December,  and  May  9,  February  8,  August  6, 
and  October  5.  In  no  year  was  September  or  November  the  month  of  maximum 
mortality. 

Table  55. — Maximum  incidence  of  mortality  and  maximum  and  minimum  incidence  of 
morbidity  from  measles  by  months ,  from  1856  to  1920,  inclusive,  and  1897  and 
1920,  inclusive,  respectively ,  and  the  percentage  of  each  to  the  total  number  of 


years. 


Months. 

Months  in  65  years  in 
which  maximum 
mortality-rate  obtains. 

Months  in  24  years  in 
which  maximum 
morbidity-rate  obtains. 

Months  in  24  years  in 
which  minimum 
morbidity-rate  obtains. 

No. 

Per  cent  to 
total  years. 

No. 

Per  cent  to 
total  years. 

No. 

Per  cent  to 
total  years. 

J  an . 

6 

9 

2 

8 

3 

13 

Feb . 

5 

8 

•  •  • 

•  •  • 

Mar . 

7 

11 

3 

13 

Apr . 

9 

14 

6 

25 

May  . 

6 

9 

8 

33 

J  une  . 

10 

15 

J  uly  . 

9 

14 

Aug . 

4 

6 

4 

17 

Sept . 

•  •  • 

•  •  • 

9 

38 

Oct . 

3 

5 

7 

29 

Nov . 

•  •  • 

•  •  • 

1 

4 

Dec . 

6 

9 

5 

21 

•  •  . 

•  •  • 

Total  . 

65 

100 

24 

100 

24 

100 

When  the  courses  of  the  monthly  annual  morbidity-  and  mortality-rates  from 
1897  to  1920  (tables  53  and  54)  are  compared,  it  is  noted  that  while,  in  general, 
the  mortality-rates  rise  and  fall  very  closely  with  the  morbidity-rates,  this 
is  by  no  means  always  the  case. 

The  shape  of  the  curve  of  the  monthly  annual  morbidity-rates  varies  greatly 
from  year  to  year.  A  rise  beginning  from  a  low  point  in  September  or  October 
may  proceed  gradually  and  smoothly,  uninterruptedly  or  sharply  and  smoothly, 
to  a  peak  in  the  winter  or  spring.  The  peak  may  be  sharp  or  flat.  The  descent 
in  the  curve  may  be  sharp  or  gradual.  The  low  point  reached  in  the  different 
years  often  varies  within  comparatively  wide  limits. 

The  influence  of  color,  age,  and  sex  on  the  incidence  of  measles  can  not  be 
determined  from  the  records  of  reported  cases  before  1921. 

Fates  specific  for  these  attributes  for  this  year  are  given  in  table  51.  It  will 
be  observed  that  while  the  great  majority  of  reported  cases,  2,052  out  of  a 
total  of  2,236,  were  in  individuals  under  the  tenth  year,  141  were  in  the  second 


FEBRILE  DISEASES 


321 


decade  and  the  remainder  were  between  the  twentieth  and  fifty-ninth  year 
of  life.  Whether  comparison  be  made  in  the  rates  for  all  ages  or  for  the  separate 
age-groups,  the  attack-rate  is  seen  to  be  much  greater  in  whites  than  in  negroes. 
For  the  age-groups  0  to  9  years  it  was  greater  by  425  per  cent.  In  this  year 
all  of  the  27  deaths  ascribed  to  measles  were  in  this  group  and  the  mortality- 
rates  for  whites  and  for  negroes  were  21  and  12,  respectively,  or  75  per  cent 
higher  in  the  latter  than  in  the  former.  The  case-fatality  rate  was  200  per 
cent  higher  in  negroes,  3.6  as  opposed  to  1.4  per  cent.  It  would  appear,  then, 
that  either  case  reporting  was  much  less  complete  among  negroes  or  with  a 
much  lower  incidence  rate  than  the  white,  the  negro,  when  he  does  develop  the 
disease,  resists  it  and  its  lethal  complications  much  less  well.  In  both  races 
and  sexes  the  morbidity  was  considerably  higher  in  the  second  than  in  the  first 
5  years  of  life;  as  between  the  sexes  the  rates  were,  on  the  whole,  higher  in 
males  than  among  females  in  whites  and  among  females  than  among  males 
in  negroes. 

Of  the  628  deaths  credited  to  the  disease  during  the  15-year  period  1905- 
1919  (table  46),  497  were  in  whites  and  131  in  negroes,  or  in  a  ratio  of 
approximately  4  to  1,  while  the  proportion  of  white  to  negroes  averaged  5.42 
to  1 ;  from  which  it  appears  that  measles  in  Baltimore  is  somewhat  more  fatal 
in  the  former  than  in  the  latter  race.  Among  the  whites  the  deaths  were  263  in 
males  as  compared  with  234  in  females,  while  among  the  negroes  there  were  67 
deaths  in  males  to  62  in  females,  indicating  a  higher  mortality  in  males  than  in 
females  in  both  races,  with  no  great  difference  in  the  proportions  of  the  number 
of  deaths  of  males  and  females  in  the  two  races. 

The  distribution  of  the  deaths  from  measles  for  age  by  sex  and  color,  as  of 
1910  (table  47),  based  on  numbers  too  small  to  warrant  generalizations,  shows 
even  higher  mortality-rate  for  males  than  females.  From  table  48  in  which 
rates  specific  for  these  categories  are  given  for  1920,  and  which  are  based  on 
larger  figures  than  those  for  1910,  it  will  be  noted  that,  as  in  the  latter  year, 
the  deaths  were  confined  to  the  first  decade  and  that  nearly  the  whole  mortality 
occurred  in  the  first  five  years  of  life.  Whereas  in  1920  in  the  various  age- 
groups  in  which  deaths  were  recorded  there  was  considerable  variation  in  the 
rates  for  the  two  races  and  sexes,  the  mortality  for  the  first  decade  of  life  as  a 
whole  varied  but  slightly  for  these  several  categories. 

This  remarkably  interesting  disease,  having  often  invaded  Baltimore  in 
the  form  of  sharply  marked  epidemics,  which  after  running  a  short  course 
apparently  died  out,  became  endemically  established  as  a  permanent  resident 
about  1819.  Since  that  date  it  has  run  a  definite  endemic  course,  broken  from 
time  to  time  by  superimposed  severer  outbreaks,  and  finally,  after  about  90 
years,  has  reached  an  average  low  rate  of  mortality  which  has  become  stabilized 
since  1900.  That  this  course  has  been  determined  by  the  interaction  of  the 
disease  upon  the  population  and  not  by  interferences  directed  to  this  end  by 
the  activities  of  the  health  department  is  clear  from  the  facts  that  the  fall  in 
the  mortality-rates  was  substantial  long  before  the  disease  was  made  reportable 
by  a  law  (1894)  which  has  never  been  complied  with  with  any  completeness, 
that  it  was  not  until  well  after  1910  that  the  health  department  made  any 
serious  attempt  to  restrict  its  spread  by  isolation,  and  that  all  the  evidence  at 
hand  indicates  that  such  efforts  as  have  been  made  to  this  end  have  been  on  the 


322  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

whole  barren  of  results.  If  morbidity-rates  during  the  last  20  years  prove 
anything,  it  is  that  the  incidence  has  increased,  while  the  case-fatality  rate 
on  the  whole  has  fallen. 


INFLUENZA. 

Epidemics  of  influenza  are  said  by  Quinan  to  have  occurred  in  Baltimore 
in  1789  and  in  1807,  but  there  have  been  preserved  no  definite  records  of 
their  duration  or  extent  in  morbidity  and  fatality.  In  the  former  year  the 
disease  was  popularly  called  "putrid  cold.”  Influenza  (table  34,  graph  11) 
was  credited  in  the  table  of  interments  with  25  deaths  in  1815,  a  death-rate  of 
53,  and  again  in  1818  with  2  deaths.  This  disease  is  not  mentioned  again  until 
1831  and  1832,  when  there  occurred  a  severe  epidemic,  beginning  in  December 
and  lasting  through  April,  causing  11  deaths  in  the  former  and  114  deaths  in 
the  latter  year,  with  death-rates  of  12  and  124,  respectively.  A  few  deaths  are 
recorded  from  the  disease  again  in  1834,  1835,  1843,  1845,  1849,  and  1850 
(with  death-rates  of  9,  13,  7,  1,  3,  and  1,  respectively),  and  then,  with  the 
exception  of  a  single  death  in  each  of  the  years  1879  and  1881,  it  disappeared 
completely  as  a  recorded  cause  of  death  until  1890. 

Whether  or  not  the  disease  died  out  completely  between  1835  and  1843  or 
remained  as  an  endemic  affection  is  not  known.  Medical  men  living  15  years 
ago  recalled  with  distinctness  the  outbreak  of  1849  as  widely  diffused  in  the 
population  and  as  more  fatal  than  is  suggested  by  the  number  of  deaths  ascribed 
to  it  in  the  statistical  records. 

It  is  more  than  probable  that  in  all  these  years  the  deaths  ascribed  to  influenza 
fell  short  of  the  true  number.  The  disease,  in  definitely  recognizable  form  at 
least,  seems  to  have  died  out  completely  during  the  40  years  beween  1851  and 
1890,  and  the  single  deaths  in  1879  and  1881  are  probably  to  be  ascribed  to 
errors  in  diagnosis.  Certain  it  is  that  the  epidemic  of  1890  took  all  of  the 
local  physicians  by  surprise,  except  the  few  remaining  who  had  gone  through 
the  epidemic  of  1849.  The  disease  had  so  entirely  disappeared  from  local 
medical  nosology  that  even  the  name  was  new  to  the  great  bulk  of  practitioners, 
and  professors  of  medicine  had  long  since  omitted  consideration  of  it  in  their 
lectures. 

When  the  disease  reappeared  in  1890  with  a  high  degree  of  incidence  and  a 
weak  lethal  capacity,  it  exhibited  the  characteristics  of  1849,  rather  than  those 
of  1815  and  1831-1832.  But  in  the  succeeding  years  it  displayed  a  quality 
entirely  new.  Instead  of  dying  out  after  a  year  or  two,  the  disease  persisted  in 
endemic  state,  and  in  no  subsequent  year  did  it  fail  to  be  credited  with  deaths. 
Upon  this  endemic  basis  there  have  occurred  a  number  of  short  waves  of  com¬ 
paratively  high  mortality-rates.  These  waves  have  recurred  in  a  rather  irregu¬ 
lar  fashion  and  their  crests  have  occupied  usually  only  1  but  occasionally  2  years. 

Until  1918  the  annual  mortality-rates  were  never  excessive  as  compared 
with  those  often  attained  by  other  members  of  the  group.  The  highest  rate,  55, 
occurred  in  1891 ;  rates  of  42,  39,  46,  25,  and  31  were  attained  in  other  years. 
The  lowest  annual  rates  were  5  in  1902  and  8  in  1913.  Between  1909  and  1917, 
inclusive,  the  highest  recorded  rate  was  21. 

The  rate  bounded  to  282  in  1918,  and  for  1919  and  1920  the  rates  were  56 
and  44,  respectively.  Particularly  in  regard  to  the  spread  of  the  peaks  and 


FEBRILE  DISEASES 


392 


depressions  as  related  to  groups  of  years  and  to  the  character  of  the  fluctuations 
in  the  rates,  the  curve  of  the  annual  rates  for  influenza  resembles  that  for 
scarlet  fever  more  closely  than  that  for  any  other  member  of  this  group.  The 
contrast  between  the  course  of  the  disease  in  its  purely  epidemic  state  and  in 
its  endemic  state  is  well  brought  out  in  the  comparison  between  the  annual 
mortality  rates  as  averaged  for  5-year  periods  (table  43,  graph  12).  With  rates 
of  13  for  1812-1815  and  of  32  for  1831-1835  and  negligible  rates  for  all  the 
intervening  periods,  the  averaged  rates  were  for  1891-1895,  36 ;  1896-1900,  21 ; 
1901-1905  and  1906-1910,  17;  1911-1915,  13;  and  1916-1920,  84. 

The  great  influenza  epidemic  of  1918  finds  no  analogies  in  either  scarlet 
fever  or  measles,  and  the  closest  approach  to  it  among  other  diseases  of  this 
group  after  they  had  become  endemic  is  that  of  small-pox  in  1858. 

It  will  be  observed  that,  during  the  period  of  endemicity,  the  chief  incidence 
of  the  disease  as  expressed  in  deaths  (table  56)  is  in  winter  and  spring,  and  that, 
though  deaths  occasionally  occur  in  July,  August,  September,  and  October, 
they  are  comparatively  few  in  number,  that  deaths  increase  in  number  in 
December,  and  that  the  greatest  fatality  more  often  falls  in  February  than 
in  any  other  month.  To  this  last  point  there  were,  however,  many  exceptional 
years  when  the  highest  fatality  occurred  in  January,  March,  or  even  April  or 
May.  As  pointed  out  above,  in  these  respects  measles  and  influenza  behave 
very  similarly.  In  the  31  years,  1890  to  1920,  the  maximum  monthly  annual 
mortality-rate,  as  expressed  in  percentages  of  the  total  number  of  years, 
occurred  as  follows,  January  29,  February  32,  March  and  April,  each  13, 
December  10,  October  3. 

The  records  contain  a  considerable  amount  of  instructive  information  con¬ 
cerning  three  of  the  great  epidemics  of  influenza  in  Baltimore. 

In  1831-1832,  the  weekly  deaths  from  influenza  and  from  all  causes  were 
published  in  the  Baltimore  American  and  Commercial  Advertiser ,  and  from 
this  source  it  has  been  possible  to  construct  table  57  in  which  the  course  of  this 
epidemic  is  well  illustrated. 

The  epidemic  began  apparently  about  the  middle  of  December  1831,  and 
lasted  until  the  end  of  April  at  least.  By  December  31  it  had  spread  widely, 
though  it  was  not  very  fatal,  for  “  many  families  have  had  six  or  eight  sick  at 
once,  yet  but  few  of  these  cases  have  ended  fatally.”  The  highest  number  of 
deaths  recorded  in  any  one  month  was  in  January,  and  in  any  one  week  in  that 
ending  the  17th  of  that  month.  As  measured  in  calendar  months,  there  was  a 
rapid  rise  during  December  and  January,  followed  by  an  abrupt  fall  in  Febru¬ 
ary,  with  a  slight  descent  from  the  level  of  the  latter  during  March,  and  a 
final  decided  drop  during  April.  During  the  whole  epidemic  period  about  12.8 
per  cent  of  the  whole  number  of  deaths  was  attributed  to  influenza. 

There  are  no  data  in  regard  to  the  number  of  cases,  but  from  the  information 
in  hand,  it  seems  probable  that  the  disease  was  very  widespread,  with  a  rela¬ 
tively  low  case  fatality. 

The  epidemic  of  1890  began  about  the  middle  of  January  and  spread  rapidly 
through  the  city,  affecting  a  very  large  proportion  of  the  population;  but, 
unlike  that  of  1831-1832  and  that  of  191.8,  it  did  not  affect  whole  families  at 
a  time.  No  deaths  were  credited  to  the  disease  during  this  month.  The  acme 
of  the  epidemic  was  during  February,  when  the  physicians  in  both  private 


Table  56. — Number  of  deaths  by  months  and  years  and  the  monthly  annual  and  annual  rates  of  death,  per  100,000  living  inhabitants,  from  in¬ 
fluenza,  from  1890  to  1920,  inclusive. 

D  =  death.  R  =  rate. 


324  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


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FEBRILE  DISEASES 


325 


practice  and  in  dispensaries  were  overburdened.  The  fatalities  attributed  to  the 
disease  were  only  10,  a  comparatively  small  number  in  comparison  with  the 
large  number  of  cases.  There  was,  however,  a  decided  increase  in  the  number 
of  deaths  from  all  causes  and  from  pneumonia,  bronchitis,  and  pulmonary 
tuberculosis.  As  a  conspicuous  cause  of  death,  influenza  did  not  show  its 
force  until  1891  and  1892.  After  the  drop  in  the  morbidity-rate  in  1893,  the 
disease  settled  into  an  endemic  state,  and  in  lethal  capacity  never  reached  its 
previous  level  until  1918. 

The  course  of  influenza  during  the  first  8  months  of  1918  was  not  unusual, 
except  in  one  feature,  namely,  the  occurrence  during  February  and  March 
among  some  men  living  in  the  eastern  section  of  the  city  and  working  daily 
in  the  government  construction  camps  just  without  the  city  limits  of  a  type 
of  influenza  characterized  by  acute  laryngitis,  often  complicated  by  severe 
hemorrhage.  Though  the  affection  often  attacked  the  household  associates  of 


Table  57. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from 
influenza  and  all  causes,  by  weeks,  for  1831  and  1832. 


D  =  death.  R  =  rate. 


Week 

ending. 

Influenza. 

All  causes. 

Week 

ending. 

Influenza. 

All  causes. 

D 

R 

D 

R 

D 

R 

D 

R 

1831 

1832 

Dec.  19... 

2 

117 

49 

2875 

Feb. 

21... 

3 

170 

52 

2943 

Dec.  27... 

9 

528 

57 

3344 

Feb. 

28. .. 

10 

566 

60 

3396 

1832 

Mar. 

5... 

9 

509 

59 

3339 

Jan.  3... 

13 

736 

60 

3396 

Mar. 

12... 

3 

170 

58 

3282 

J an.  10. . . 

12 

679 

58 

3282 

Mar. 

20. . . 

8 

453 

60 

3396 

Jan.  17... 

15 

849 

55 

3113 

Mar. 

27... 

4 

226 

51 

2886 

Jan.  24. . . 

4 

226 

44 

2490 

Apr. 

3. .. 

5 

283 

48 

2716 

Jan.  31... 

10 

566 

49 

2773 

Apr. 

10. . . 

4 

226 

49 

2773 

Feb.  7... 

9 

509 

52 

2943 

Apr. 

17... 

•  •  • 

•  •  • 

43 

2434 

Feb.  14... 

3 

170 

49 

2773 

Apr. 

24... 

2 

113 

27 

1528 

these  men;  it  spread  to  other  households  but  rarely.  Both  lobar  and  broncho 
pneumonia  were  more  prevalent  than  usual  in  the  spring  of  1918,  and  a  con¬ 
siderable  proportion  of  the  cases  of  pneumonia,  complicating  cases  of  measles 
and  whooping-cough  during  the  winter  and  spring  months,  conformed  to  the 
type  of  acute  interstitial  pneumonia  described  by  MacCallum  and  others  in 
army  camps  and  associated  with  the  presence  of  Streptococcus  hemolyticus. 
This  highly  fatal  type  of  pneumonia  had  become  well  established  in  the  city 
before  the  beginning  of  the  great  influenza-pneumonia  epidemic  in  September. 
During  the  latter  part  of  August  and  early  September  there  was  a  sharp  out¬ 
break  of  influenza  among  the  military  and  labor  forces  in  the  construction 
and  other  army  camps  to  the  east  and  southeast  of  the  city,  and  during  the  third 
week  of  September,  just  as  in  the  spring,  cases  of  the  disease  in  very  severe 
type  occurred  first  in  the  eastern  section  of  the  city  among  men  residing  there, 
but  working  in  the  army  camps,  where  they  came  into  contact  with  the  army 
personnel.  The  disease  spread  first  to  the  household  associates  of  these  men, 
and  then  within  a  short  time  over  the  whole  eastern  section  of  the  city.  In  the 
last  week  of  September,  influenza  of  the  same  severe  type  appeared  in  the 


326  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

southern  section  of  the  city,  bounding  the  west  side  of  the  basin  and  harbor,  the 
seat  of  shipyards  and  docks,  where  the  inhabitants  were  most  intimately  asso¬ 
ciated  with  overseas  shipping.  In  a  short  time  the  disease  spread  rapidly  in 
the  neighboring  wards.  It  is  clearly  established  that  the  malady  first  attacked, 
in  severe  form,  at  least,  those  whose  work  brought  them  into  association  with 
the  army.  The  wards  of  the  north  and  northwestern  sections  of  the  city  were 
invaded  somewhat  later.  There  were  probably  early  in  the  epidemic  a  number 
of  foci  in  various  parts  of  the  city  that  did  not  come  so  sharply  to  the  attention 
of  the  health  department. 

Influenza  was  included  among  the  reportable  diseases  shortly  after  the 
beginning  of  the  epidemic,  and  the  first  cases  (10  in  number)  were  reported 
on  September  26.  Between  this  date  and  December  27,  21,902  cases  were 
reported,  but,  as  it  was  for  some  weeks  a  physical  impossibility  for  an  over¬ 
worked  profession  to  report  cases  with  any  degree  of  completeness,  it  is  probable 
that  but  one-third  of  the  actual  number  of  cases  was  reported  and  that  75,000 
would  be  an  underestimate.  From  the  daily  record  it  appears  that  the  peak  of 
the  epidemic  was  reached  about  October  10,  when  the  highest  number  of  case 
reports  (1962)  was  received.  By  October  29  the  daily  number  of  case  reports 
had  fallen  to  514,  and  by  the  31st  to  90.  During  November  the  number  fell  to 
a  lower  level.  There  was  a  distinct  rise  in  December,  which  became  more  marked 
at  the  close  of  the  month. 

The  course  of  the  disease  by  weeks  from  September  7,  1918,  to  April  25, 
1919,  is  shown  by  the  weekly  annual  rates  for  influenza,  together  with  the 
weekly  annual  rates  for  deaths  from  all  causes,  in  table  58.  The  curves  for 
these  rates,  with  the  rapid  rise  to  a  high  peak,  between  the  week  ending  Sep¬ 
tember  28,  and  the  weeks  ending  October  12  and  19,  for  morbidity  and  mor¬ 
tality  respectively,  and  the  succeeding  declines,  almost  as  sharp,  reaching  a 
low  point  the  last  week  in  November,  are  distinctive  and  entirely  unlike  those 
of  previously  recorded  epidemics  of  influenza  in  Baltimore.  The  curves  for 
the  ensuing  winter  and  spring  followed  the  usual  endemic  course,  very  much 
as  if  this  overwhelming  outbreak  of  September,  October,  and  November  had 
not  occurred.  This  outbreak  was  for  Baltimore  exceptional  in  its  season  of 
occurrence,  the  rapidity  of  its  course,  and  its  high  fatality.  The  full  lethal 
force  of  this  outbreak  is  reflected  more  completely  by  the  rates  for  deaths 
from  all  causes  than  by  those  for  influenza  alone;  for  by  the  rules  of  classi¬ 
fication,  while  deaths  of  influenza  and  broncho-pneumonia  are  classified 
under  influenza,  those  ascribed  to  influenza  and  lobar  pneumonia,  of  which 
there  are  many,  and  influenza  complicating  such  diseases  as  typhoid  fever  and 
whooping-cough  are  not.  Influenza  was  assigned  also  as  a  contributory  cause 
of  death  in  a  number  of  instances  in  connection  with  pulmonary  tuberculosis, 
organic  diseases  of  the  heart,  and  other  affections.  There  was  a  large  number 
of  deaths  assigned  to  primary  broncho  and  lobar  pneumonia  without  influenza. 
It  is  certain  that  in  many  instances  the  diagnosis  between  broncho-pneumonia 
and  lobar  pneumonia  complicating  influenza  was  in  error,  and  that  many,  if 
not  most,  of  the  cases  diagnosed  as  lobar  pneumonia  really  belonged  to  the 
former  category  and  should  in  truth  under  the  rules  have  been  classified  under 
influenza.  As  a  matter  of  fact,  there  is  in  the  light  of  present  knowledge  no 
adequate  reason  for  this  distinction. 


FEBRILE  DISEASES 


327 


Neither  the  reported  cases  nor  the  deaths  of  influenza  were  analyzed  for 
distribution  according  to  age.  In  regard  to  color  and  sex,  the  81  deaths  of 
influenza  occurring  between  January  1  and  September  1  were  divided  as  follows  : 
White,  total  52,  male  25,  females  27 ;  colored,  total  29,  male  13,  female  16. 
The  differences  in  the  number  of  fatalities  by  sex  were  not  great,  but  the 


Table  58. — Number  of  cases  arid  deaths  and  morbidity  and  mortality  rates,  per  100,000 
living  inhabitants,  from  influenza  and  number  of  deaths  and  mortality  rate  from 
all  causes,  by  weeks,  for  191S  and  1919. 


O  =  cases.  R  =  rate.  D  =  death. 


Week  ending. 

Influenza. 

Influenza. 

All  causes. 

C 

R 

D 

R 

D 

R 

1918 

Sept.  7 . 

•  •  • 

•  •  • 

1 

8 

184 

1330 

Sept.  14 . 

•  •  • 

•  •  • 

•  •  • 

•  •  • 

190 

1374 

Sept.  21 . 

•  •  • 

•  •  • 

•  •  • 

•  •  • 

163 

1179 

Sept.  28 . 

53 

447 

3 

25 

194 

1403 

Oct.  5 . 

3165 

26718 

71 

599 

321 

2321 

Oct.  12 . 

8945 

75511 

344 

2904 

793 

5733 

Oct.  19 . 

5416 

45720 

614 

5183 

1691 

12226 

Oct.  26 . 

2374 

20041 

327 

2760 

1358 

9818 

Nov.  2 . 

588 

4964 

139 

1173 

613 

4432 

Nov.  9 . 

75 

633 

39 

329 

314 

2270 

Nov.  16 . 

116 

979 

14 

118 

234 

1692 

Nov.  23 . 

60 

507 

4 

34 

238 

1721 

Nov.  30 . 

94 

794 

12 

101 

212 

1533 

Dec.  6 . 

164 

1384 

29 

245 

230 

1663 

Dec.  13 . 

256 

2161 

22 

186 

248 

1793 

Dec.  20 . 

324 

2735 

21 

177 

220 

1591 

Dec.  27 . 

272 

2296 

17 

144 

235 

1699 

1919 

J tin.  3*  ••••••••  t  ••  •  • 

294 

2126 

14 

101 

227 

1641 

Jan.  10 . 

402 

2907 

24 

174 

279 

2017 

Jan.  17 . 

978 

7071 

31 

224 

289 

2090 

Jan.  24 . 

1445 

10447 

61 

441 

401 

2899 

Jan.  31 . 

847 

6124 

53 

383 

362 

2617 

Feb.  7 . 

355 

2567 

43 

311 

364 

2632 

Feb.  14 . 

262 

1894 

42 

304 

313 

2263 

Feb.  21 . 

199 

1439 

23 

166 

335 

2422 

Feb.  28 . 

173 

1251 

22 

159 

272 

1967 

Mar.  7 . 

115 

831 

11 

80 

254 

1836 

Mar.  14 . 

74 

535 

11 

80 

251 

1815 

Mar.  21 . 

21 

152 

15 

108 

219 

1583 

Mar.  28 . 

21 

152 

10 

72 

212 

1533 

Apr.  4 . 

12 

87 

3 

22 

211 

1526 

Apr.  11 . 

14 

101 

3 

22 

230 

1663 

Apr.  18 . 

5 

36 

3 

22 

178 

1287 

Apr.  25 . 

4 

29 

4 

29 

233 

1685 

disease  was  much  more  fatal  for  negroes  than  for  whites,  the  ratio  of  deaths 
being  as  5  to  3,  in  a  population  with  whites  in  the  proportion  of  5.75  whites 
to  1  negro.  Of  the  1,662  deaths  from  influenza  between  September  1  and 
December  31,  there  were  whites,  total  1,403,  males  693,  females  710,  and 
negro,  total  259,  males  123,  females  136.  Here  there  were  no  significant 
differences  in  distribution  either  by  sex  or  by  color.  The  incidence  of  influenza 


328  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

deaths  in  white  and  negro  was  in  the  proportion  of  about  5  to  1,  in  a  popula¬ 
tion  racially  distributed  in  a  ratio  of  about  5.75  to  1.  So  in  the  period  of  the 
epidemic  the  most  usual  position  of  whites  as  to  fatality  from  influenza  was 
largely  lost.  This  change  is  clearly  shown  in  table  59.  As  between  the  sexes 
there  were  no  significant  differences  in  the  rates  for  white,  but  among  negroes 
the  rates  for  males  were  distinctly  higher  than  those  for  females. 

The  point  has  been  made  that  the  influenza  epidemic  of  1918  was  accom¬ 
panied  by  epidemic  incidence  of  broncho-pneumonia,  and  that  the  number  of 
deaths  credited  to  influenza  fell  far  short  of  the  true  number,  because,  on 
account  of  the  rules  of  classification,  deaths  ascribed  to  this  disease  with  lobar 
pneumonia  wTere  classified  under  the  latter  rubric.  This  is  fully  borne  out  by 
table  59,  in  which  it  will  be  observed  that  during  the  period  of  the  influenza 
epidemic,  the  monthly  annual  rates  for  both  broncho-pneumonia  and  lobar 
pneumonia  were  not  only  much  higher  than  normal,  but  moved  synchronously 
with  those  for  influenza.  In  both  cases  the  rates  for  negroes  were  higher  than 
those  for  whites,  and  with  the  exception  of  broncho-pneumonia  in  the  negro, 
in  whom  the  reverse  occurred,  the  recorded  mortality  was  decidedly  greater 
among  males  than  among  females  of  both  races. 

The  high  fatality  of  the  epidemic  outburst  was  apparently  due  to  the  unusual 
virulence  of  the  disease  itself  and  to  the  fact  that  it  happened  to  occur  at  a 
time  when  Streptococcus  hemolyticus  broncho-pneumonia  was  prevalent. 

As  elsewhere,  the  disease  spread  through  the  community  like  wildfire,  striking 
down  whole  families,  sometimes  all  at  once,  and  sometimes  the  various  indi¬ 
viduals  in  succession.  In  the  height  of  the  outbreak  physicians,  depleted  in 
numbers  owing  to  the  war,  could  not  respond  to  all  of  their  calls ;  the  hospitals, 
crippled  by  lack  of  full  corps  of  physicians,  nurses,  and  orderlies,  were  unable 
properly  to  care  for  the  crowds  demanding  their  care,  and  every  public  and 
private  service  was  seriously  embarrassed. 

The  figure  cut  by  the  health  department  was  distressing.  In  the  middle  of 
September,  the  writer,  realizing,  as  must  any  one  familiar  with  what  is  known 
of  the  natural  history  of  influenza  in  general  and  acquainted  with  its  recent 
behavior  in  Europe  and  in  New  England  at  the  time,  that  it  was  hopeless  to 
expect  by  the  use  of  any  known  methods  to  prevent  its  entrance  into  the  city 
or  to  stop  its  spread  when  it  entered,  advised  the  commissioner  of  health  not 
to  complicate  the  situation  by  fruitless  attempts  at  interference,  but  to  organize 
about  the  health  department  all  the  various  medical,  nursing,  and  relief 
agencies  for  the  care  of  those  who  must  inevitably  be  stricken.  Finally  adopting 
this  view  after  ascertaining  that  it  was  acquiesced  in  by  a  number  of  leading 
physicians  whom  he  consulted,  plans  were  laid  to  organize  the  social  forces 
for  aid.  Before  anything  concrete  was  accomplished,  however,  the  epidemic 
was  well  under  way,  and  at  the  critical  time,  falling  under  the  influence  of  the 
remarkable  circular  letter  of  the  Surgeon  General  of  the  United  States  Public 
Health  Service,  embodying  recommendations  of  archaic  type,  and  bowing,  in 
the  face  of  knowledge  and  common  sense,  to  authority,  the  commissioner 
spent  his  energies  in  issuing  orders  which,  if  obeyed,  would  have  paralyzed 
every  activity  necessary  among  the  inhabitants  of  a  great  city  in  the  midst  of 
war.  So  far  did  restrictive  regulations  extend  that  for  some  days  it  was  a 
criminal  offense  for  a  junk-dealer  to  sell  scrap-iron.  In  consequence,  the  staff 
of  the  health  department  devoted  its  energies  mainly  to  trying  to  restrict 


FEBRILE  DISEASES 


329 


Table  59. 
INFLUENZA. 

D  =  death.  R  =  rate. 


White. 

Colored. 

Total. 

Total. 

Male. 

Female. 

Total. 

Male. 

Female. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1918 
Jan.  .. 

24 

46 

18 

41 

7 

33 

11 

49 

6 

71 

4 

104 

2 

44 

Feb.  .. 

14 

30 

10 

25 

6 

30 

4 

20 

4 

53 

3 

86 

1 

24 

Mar.  . . 

20 

38 

12 

27 

5 

23 

7 

31 

8 

95 

5 

130 

3 

66 

Apr.  . . 

12 

24 

7 

16 

3 

14 

4 

19 

5 

61 

•  •  •  • 

•  •  •  • 

5 

113 

May  . . 

6 

11 

4 

9 

3 

14 

1 

4 

2 

24 

1 

26 

1 

22 

J une  . . 

2 

4 

1 

2 

1 

5 

•  •  •  • 

•  •  •  • 

1 

12 

•  •  •  • 

•  •  •  • 

1 

23 

J uly  . . 
A  U£T. 

1 

2 

1 

12 

1 

22 

Sept.  . . 

11 

22 

10 

23 

5 

23 

5 

23 

1 

12 

1 

27 

•  •  •  • 

•  •  •  • 

Oct.  . . 

1464 

2791 

1245 

2826 

600 

2750 

645 

2901 

219 

2604 

102 

2650 

117 

2566 

Nov.  . . 

93 

183 

70 

164 

44 

208 

26 

121 

23 

283 

10 

268 

13 

295 

Dec.  . . 

94 

179 

78 

177 

44 

202 

34 

153 

16 

190 

10 

260 

6 

132 

Total  . 

1741 

282 

1455 

281 

718 

279 

737 

282 

286 

289 

136 

300 

150 

279 

BRONCHOPNEUMONIA. 


1918 
Jan.  . . 

81 

154 

52 

118 

28 

128 

24 

108 

29 

345 

13 

338 

16 

351 

Feb.  .. 

120 

253 

85 

214 

58 

294 

27 

134 

35 

461 

12 

345 

23 

559 

Mar.  . . 

85 

162 

56 

127 

31 

142 

25 

112 

29 

345 

18 

468 

11 

241 

Apr.  . . 

86 

169 

53 

124 

28 

133 

25 

116 

33 

406 

12 

322 

21 

476 

May  . . 

50 

95 

34 

77 

18 

82 

16 

72 

16 

190 

8 

208 

8 

175 

June  . . 

29 

57 

24 

56 

9 

43 

15 

70 

5 

61 

3 

81 

2 

45 

J  uly  . . 

24 

46 

13 

30 

9 

41 

4 

18 

11 

131 

4 

104 

7 

154 

Aug.  .. 

11 

21 

5 

11 

3 

14 

2 

9 

6 

71 

1 

26 

5 

110 

Sept.  . . 

24 

47 

15 

35 

8 

38 

7 

33 

9 

111 

4 

107 

5 

113 

Oct.  . . 

357 

681 

288 

654 

160 

733 

128 

576 

69 

821 

20 

520 

49 

1075 

Nov.  . . 

61 

120 

51 

120 

27 

128 

24 

112 

10 

123 

3 

81 

7 

159 

Dec.  . . 

66 

126 

53 

120 

32 

147 

21 

94 

13 

155 

4 

104 

9 

197 

Total  . 

994 

161 

729 

141 

411 

160 

318 

121 

265 

268 

102 

225 

163 

304 

LOBAR  PNEUMONIA. 


1918 
Jan.  .. 

129 

246 

90 

204 

53 

243 

37 

166 

39 

464 

24 

623 

15 

329 

Feb.  .. 

134 

283 

89 

224 

54 

274 

35 

174 

45 

592 

31 

892 

14 

340 

Mar.  . . 

138 

263 

71 

161 

42 

192 

29 

130 

67 

797 

42 

1091 

25 

548 

Apr.  . . 

90 

177 

64 

150 

35 

166 

29 

135 

26 

320 

17 

456 

9 

204 

May  . . ' 

36 

69 

19 

43 

12 

55 

7 

31 

17 

202 

12 

312 

5 

110 

June  . . 

25 

49 

15 

35 

9 

43 

6 

28 

10 

123 

5 

134 

5 

113 

J  uly  . . 

13 

25 

9 

20 

5 

23 

4 

18 

4 

48 

1 

26 

3 

66 

Aug.  .. 

12 

23 

6 

14 

4 

18 

2 

9 

6 

71 

2 

52 

4 

88 

Sept.  . . 

39 

77 

29 

68 

23 

109 

6 

28 

10 

123 

7 

188 

3 

68 

Oct.  . . 

1696 

3233 

1409 

3198 

784 

3593 

625 

2811 

287 

3413 

155 

4026 

132 

2895 

Nov.  . . 

103 

203 

75 

176 

52 

246 

23 

107 

28 

344 

14 

376 

14 

317 

Dec.  . . 

118 

225 

92 

209 

54 

247 

38 

171 

26 

309 

16 

416 

10 

219 

Total  . 

2533 

410 

1968 

379 

1127 

439 

841 

321 

565 

571 

326 

719 

239 

445 

330  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

absolutely  essential  activities  or  in  explaining  to  irate  and  embarrassed  citizens 
how  and  when,  if  at  all,  they  could,  within  the  regulations,  sell  or  buy  food, 
clothing,  and  drugs,  go  to  and  from  their  work,  or  get  married  or  buried. 
Not  only  schools,  churches,  and  theaters,  but  many  businesses,  were  practically 
closed.  The  only  real  service  was  done  by  the  scant  force  of  nurses  in  helping 
some  of  the  sick,  by  one  officer  in  getting  a  sufficient  number  of  common  coffins 
made  to  break  the  coffin  monopoly,  and  by  another  in  assigning  laborers  to 
bury  the  accumulated  dead  at  cemeteries.  There  was  no  coordination  of  helping 
agencies,  each  of  which  did  the  best  it  could  without  special  direction  and 
assistance.  In  the  health  department  chaos  reigned  and  futile  conflicting 
restrictive  orders  gushed  forth  in  ever-increasing  volume. 

SUMMARY. 

The  curve  for  the  annual  mortality  rates  for  this  group  of  diseases  as  a 
whole  (table  34,  graphs  11  and  13)  shows  not  only  considerable  variations  from 
year  to  year,  but  a  number  of  very  distinct  and  usually  sharply  crested  waves 
which  extend  over  periods  of  several  years. 

The  wide  fluctuations  in  the  total  rates  are  caused  in  part  by  similar  changes 
in  the  rates  for  the  several  members  of  the  group  and  in  part  by  the  fact  that 
the  various  members  enter  at  different  times  and  some  of  them,  after  their 
first  entry,  drop  out  for  longer  or  shorter  periods.  For  these  reasons  it  is  im¬ 
practicable  to  represent  graphically  and  to  analyze  sharply  the  contribution  of 
each  to  the  whole.  The  peaks  of  the  successive  waves  of  the  total  annual 
mortality  rates  tend  to  become  higher  up  to  1872.  After  this  date,  with  the 
exception  of  the  peak  of  1883,  they  tend  to  fall  in  an  irregular  manner  to  much 
lower  levels  until  1918,  when  there  is  a  sharp  reaction  to  a  relatively  high 
level.  Years  with  exceptionally  high  rates  were  as  follows:  1823,  272;  1834 
and  1837,  each,  303;  1844,  270;  1845,  296;  1848,  314;  1852,  353;  1857,  328; 
1858,  434;  1862,  338;  1864,  304;  1872,  473;  1883,  305;  1918,  296.  The  high 
total  rates  of  many  of  these  peak  years,  as  well  as  in  other  years,  were  often 
due  to  extraordinarily  high  rates  for  a  single  disease.  With  the  possible  excep¬ 
tion  of  small-pox  and  varicella,  the  various  numbers  of  the  group  developed 
high  and  low  rates  of  mortality  apparently  quite  independently  of  each  other. 
There  is  no  striking  and  constant  similarity  in  the  course  of  their  curves  as 
regards  years  of  high  and  low  rates. 

From  the  total  rate  and  the  rates  for  the  various  diseases,  as  averaged  for 
5-year  periods  from  1811  to  1920  (table  43,  graphs  12  and  14),  a  clearer  idea 
may  be  gotten  of  the  death  toll  of  the  group  as  a  whole  and  the  relative 
importance  of  the  contributions  of  its  various  members.  Beginning  with  a 
total  rate  of  83  in  1812-1815,  there  was  a  drop  to  48  in  1815-1820,  a  rise  to 
132  in  1821—1825,  and  a  fall  to  53  in  1826—1830.  Influenza  in  the  first  period 
and  measles  and  small-pox  during  the  whole  time  were  the  chief  contributors. 
Due  very  largely  to  scarlet  fever  and  in  some  degree  to  influenza,  the  total 
rate  jumped  to  202  in  1831-1835.  After  falling  to  154  in  1836-1840,  the  rate 
rose  continuously  to  233  in  1856-1860.  During  the  30  years  from  1831  to  1860, 
scarlet  fever  was  by  far  the  largest  single  contributor  to  the  total  rate ;  small-pox 
played,  on  the  whole,  a  less  important  part  than  measles;  and  influenza  did 


FEBRILE  DISEASES 


331 


not  appear  significantly  after  1835.  After  a  moderate  decline  to  215  in  1861- 
1865  and  influenced  very  largely  by  the  falling-olf  in  the  mortality  from  scarlet 
fever,  the  rate  fell  abruptly  to  107  in  1866-1870.  Owing  particularly  to 
decided  increases  in  the  rates  for  small-pox  and  scarlet  fever,  the  total  rate 
reached  to  248  in  1871-1875.  In  association  with  changes  in  the  rates  for  small¬ 
pox  and  measles,  the  total  rate  declined  in  1876-1880  to  133  and  in  1881-1885 
reached  147.  A  remarkable  fall  in  the  total  rate  to  47  in  1886-1890  was  brought 
about  by  the  final  disappearance  of  small-pox  as  a  serious  cause  of  death  and 
by  a  distinct  drop  in  the  rate  for  scarlet  fever.  The  rise  of  the  total  rate  to 
72  in  1891-1895  was  due  very  largely  to  the  reentrance  of  influenza,  for  the 
rise  in  the  rate  for  scarlet  fever  was  largely  offset  by  a  fall  for  that  of  measles. 
The  descent  in  the  total  rate  to  33  in  1896-1900  was  associated  with  the 


Graph  16  (from  table  43).  Crude  mortality-rates  from  small-pox,  varicella, 
scarlet  fever,  measles,  and  influenza,  averaged  by  10-year  periods,  from  1812 
to  1920,  inclusive. 

decline  of  measles  and  scarlet  fever  to  new  low  levels  and  to  a  considerable 
decrease  in  the  rate  for  influenza.  The  total  rate  now  stood  at  the  lowest  level 
ever  attained  in  our  records.  Slight  changes  in  the  rates  for  all  three  contribu¬ 
tors  carried  the  rate  for  1901-1905  up  to  37,  and  brought  it  down  to  31  in 
1906-1910  and  27  in  1911-1915.  A  very  considerable  rise  in  the  rate  for 
influenza  caused  the  total  rate  to  reach  94  in  1916-1920.  It  will  be  observed 
that  for  the  group  as  a  whole  the  rates  ascended  in  a  somewhat  irregular  fashion 
until  1871-1875,  and  that,  with  this  date  as  a  turning-point,  they  declined 
by  irregular  steps.  But  for  the  reentrance  of  influenza  upon  the  scene  in  1890, 
this  decline  would  have  been  much  less  irregular  and  much  more  marked,  and 
by  1900  the  rate  for  the  whole  group  would  have  become  negligible. 

The  curve  of  the  total  rates  as  averaged  for  10-year  periods  (table  43  and 
graph  16)  rose  from  64  in  1812-1820  to  the  peak  rate  of  225  in  1851-1860. 


332  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

After  a  drop  to  161  in  1861-1870,  succeeded  by  a  rise  to  191  in  1871-1880,  there 
was  a  continuous  decline  to  34  in  1901-1910.  This  was  followed  by  a  reaction  to 
60  in  1911-1920.  Thus,  after  100  years,  the  mortality-rate  for  this  group  as  a 
whole  has  returned  to  the  same  level  from  which  it  started.  Measles,  scarlet 
fever,  and  small-pox  were  the  longest  and  most  weighty  contributors  to  the 
total  rate,  and  of  these  scarlet  fever  was  by  far  the  most  important.  It  was 
characterized  by  the  highest  averaged  rates  and  determined  the  shape  of  the 
curve  of  the  total  rate  for  most  of  the  period.  Measles  ran,  on  the  whole,  the 
more  consistently  even  course.  Of  the  three,  small-pox  fluctuated  the  most 
widely  and  soonest  fell  in  importance.  Influenza  contributed  forcibly  at  the 
beginning  and  end  of  the  period,  and  after  1900  it  determined  the  shape 
of  the  curve.  The  influence  of  chicken-pox  was  comparatively  negligible 
throughout. 

The  percentage  of  the  number  of  deaths  from  this  group  of  diseases  to  the 
number  of  deaths  from  all  causes  varied  considerably  at  different  periods. 
Percentages  as  high  as  11,  12,  13,  14,  and  15  occurred  in  several  years.  In 
1858,  16  per  cent  of  all  deaths  were  ascribed  to  these  affections.  After  1883, 
as  judged  by  this  criterion,  they  sank  to  a  relatively  unimportant  position. 
During  the  109  years  through  which  their  course  has  been  traced,  the  members 
of  this  group  of  diseases  have  disclosed  very  clearly  and  distinctly  certain 
important  attributes  which  must  be  regarded  as  inherently  characteristic  of 
their  natural  history  in  a  population  of  the  size  and  composition  of  Baltimore. 
In  the  period  under  consideration,  each  except  chicken-pox,  which  was  appar¬ 
ently  already  endemically  established,  has  repeatedly  entered,  attacked  con¬ 
siderable  numbers  in  the  population,  and  then,  certainly  as  causes  of  death  and 
as  clinically  recognizable  diseases,  completely  disappeared,  often  for  a  con¬ 
siderable  period  of  years. 

The  disappearance  of  each  of  these  diseases  from  the  community  after  these 
epidemic  outbreaks  has  occurred  in  the  absence  of  the  use  of  any  measures  or 
at  least  of  reasonably  adequate  measures,  designed  to  control  their  spread. 
When  in  this  purely  epidemic  phase,  each  of  these  diseases  has  invariably  run 
its  course  in  from  6  to  36  months.  After  repeated  experiences  of  this  character, 
small-pox,  measles,  scarlet  fever,  and  influenza,  each  in  turn  and  after  some 
particular  epidemic  invasion,  have  became  endemically  established,  with  cases 
and  deaths  each  year  for  a  number  of  years  in  succession.  Finally,  after  becom¬ 
ing  endemically  intrenched,  they  have  all  exhibited  certain  common  character¬ 
istics  in  their  succeeding  course.  The  first  of  these  is  the  persistence  of  the 
epidemic  qualities,  as  shown  by  exacerbations  of  incidence  and  fatality  extend¬ 
ing  over  several  years,  followed  by  periods  of  remission  or  depression  during 
which  incidence  and  fatality  were  much  reduced.  These  rest  periods  varied  in 
length  for  the  different  diseases  and  for  the  same  disease  at  different  times 
in  its  history.  A  second  characteristic  is  the  occurrence  of  long  undulations  in 
the  morbidity  and  mortality  curves  covering  periods  measured  by  a  number 
of  years.  A  third  characteristic,  shown  particularly  by  small-pox,  measles,  and 
scarlet  fever,  the  diseases  of  greatest  fatality  longest  endemically  established, 
is  a  gradual  loss  of  lethal  force,  without,  in  the  case  of  measles  and  scarlet  fever, 
loss  of  capacity  to  attack.  Even  influenza,  as  established  endemically  between 
1891  and  1917,  showed  on  the  whole  a  distinct  impairment  in  force  of  mor¬ 
tality.  Though  deaths  from  varicella  have  always  been  comparatively  few  in 


FEBKILE  DISEASES 


333 


number,  the  course  of  its  mortality-rates  indicates  the  same  quality  of  dimin¬ 
ishing  lethal  power.  A  fourth  characteristic  common  to  measles,  scarlet  fever, 
chicken-pox,  and  perhaps  influenza  during  their  period  of  endemicity  is  an 
increase  in  invasive  capacity,  or  attack-rate,  as  they  have  lost  in  lethal  force. 

Among  other  attributes  held  in  common,  these  affections  have  in  the  main  the 
same  seasonal  distributions.  A  studv  of  their  incidence  fails  to  disclose  evidence 
that  one  exerts  any  exclusive  influence  upon  another.  Two  or  more  have 
existed  in  intensive  form  in  the  community  at  the  same  time,  and  severe  out¬ 
breaks  of  several  have  occurred  in  the  same  year. 

As  has  been  brought  out  in  consideration  of  each  of  these  diseases  separately, 
the  usual  measures  of  a  restrictive  sort  to  prevent  the  spread  of  any  of  them 
were  not  undertaken  until  late  in  this  history.  None  of  them  was  made  report- 
able  b}r  law  until  1882,  and  none,  except  small-pox,  was  reported  with  any 
reasonably  accurate  completeness  before  1897.  The  usual  restrictive  measures, 
including  fumigation,  were  not  begun  against  scarlet  fever  until  after  1900, 
or  against  measles  until  after  1910 — in  each  case  long  after  the  disease  had 
ceased  to  be  attended  with  high  rates  of  mortality.  Against  influenza,  spar¬ 
ingly  reported  since  the  fall  of  1918,  no  measures  have  been  attempted. 
Accommodations  for  hospitalization  of  more  than  a  small  percentage  of  patients 
and  contacts,  except  for  small-pox  since  1885,  have  never  been  available. 

The  conclusion  is  inevitable  that  all  of  these  diseases  have  defied  all  the 
restrictive  measures,  such  as  quarantine,  isolation,  and  disinfection,  which 
have  been  directed  to  control  their  spread,  and  that,  as  all  substantial  decreases 
in  their  mortality-rates  occurred  before  such  measures  were  seriously  attempted, 
decline  in  their  mortality  and  increase  in  their  morbidity  were  altogether 
independent  of  interferences  of  this  character.  It  can  not  be  denied,  however, 
that  the  application  of  these  measures  in  recent  times  may  not  have  often 
served  to  protect  certain  individuals  and  groups  of  individuals  from  attacks. 
On  the  other  hand,  it  would  be  idle,  in  the  face  of  established  facts  to  the 
contrary,  to  claim  that  on  the  whole  these  methods  have  in  any  serious  degree 
influenced  the  natural  courses  of  these  diseases  in  the  community.  That  the 
course  of  small-pox  has  been  modified,  but  not  controlled,  by  vaccination  seems 
certain. 

In  regard  to  the  question  of  morbidity,  as  true  now  as  when  written  in  1838, 
are  the  words  of  Dr.  John  H.  Briscoe,  consulting  physician  to  the  board  of 
health : 

“We  have  had  scarlet  fever  lingering  with  us,  but  how  long  it  is  to  remain  the 
undersigned  has  no  speculation  to  offer,  nor  has  he  on  the  general  character  of  epidemic, 
contagious,  or  infectious  disease,  more  than,  that  small-pox  will  continue  to  recur 
locally  as  an  endemic  or  epidemic  disease  until  vaccination  has  become  universal 
throughout  the  land ;  that  scarlet  fever  and  measles  occur  under  no  fixed  laws,  and  both 
seem  disposed  to  abide  with  us.” 

To  what  degrees  the  changes  resulting  in  the  present  status  of  the  attack  ana 
fatality  rates  of  these  diseases  have  resulted  from  modifications  of  the  several 
viruses,  of  the  population,  and  of  the  environment  are  matters  of  speculation. 
From  the  standpoint  of  natural  selection  as  a  possible  influence,  it  may  be 
significant  that  the  highest  incidence  and  the  highest  death-rates  for  those 
members  of  the  group  which  have  been  most  fatal  have  been  among  individuals 
too  young  to  have  had  progeny.  In  consequence,  those  dying  of  any  one  of 


334  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

these  diseases  have,  in  general,  failed  to  perpetuate  a  specially  susceptible 
strain,  and  survivors  of  attacks  have  had  the  advantage  of  transmitting  to 
offspring  their  natural  and  acquired  resistance  to  death  from  that  particular 
disease. 

For  diseases  the  chances  of  general  dissemination  of  whose  viruses  are  depen¬ 
dent  very  largely  upon  the  convalescent  carriers — and  it  seems  probable  that 
all  the  members  of  this  group  belong  to  this  class — it  is  obvious  that  high 
case-fatality  rates  must  affect  unfavorably  and  low  fatality-rates  must  effect 
favorably,  their  opportunities  to  spread  in  the  community.  Any  logically  satis¬ 
factory  explanation  of  the  variation  in  morbidity  and  mortality  exhibited  by 
these  diseases  must  account  for  the  conditions,  environmental  and  other,  that, 
on  the  one  hand,  affect  the  aggressiveness  of  the  organisms  to  attack  and  to 
kill,  and,  on  the  other  hand,  that  raise  or  lower  the  resistance  of  the  population. 
Definite  data  for  framing  such  an  explanation  are  wholly  lacking. 

ACUTE  INFLAMMATORY  AFFECTIONS  OF  THE 

RESPIRATORY  TRACT. 

Under  this  heading  are  grouped  whooping-cough,  diphtheria,  and  bronchitis 
and  pneumonia.  The  first  two  have  long  been  recognized  clinically  and  statisti¬ 
cally  as  definite  specific  diseases. 

Whooping-cough,  readily  distinguished  in  typical  cases  by  the  characteristic 
cough,  is  hardly  likely  to  be  confused  clinically  to  a  serious  degree  with  other 
affections.  It  has  no  doubt  been  confused  in  the  statistical  nosology,  however, 
with  its  chief  complications — bronchitis  and  pneumonia.  The  discovery  in 
1910  of  B.  'pertussis,  its  probable  causative  agent,  has  from  the  practical  stand¬ 
point  added  nothing  of  importance  to  exactness  of  diagnosis. 

Diphtheria,  on  the  other  hand,  until  the  discovery  of  its  cause,  B.  diphtherice, 
in  1884,  was  the  subject  of  much  confusion  with  other  acute  affections  of  the 
throat,  nose,  and  larynx.  Hardly  ever  mistaken  when  in  epidemic  form,  doubt¬ 
less  in  isolated  cases  it  has  been  confused  clinically  and  therefore  statistically 
with  other  affections.  Again,  on  account  of  the  not  infrequent  occurrence  of 
pneumonia  as  a  complication,  it  is  likely  that  the  latter  has  been  credited 
with  some  deaths  due  primarily  to  the  former.  At  the  present  day  there  is 
perhaps  no  other  serious  infectious  disease  whose  natural  history  is  so  fully 
known.  While  other  inflammatory  diseases  of  the  organs  usually  affected  by 
diphtheria  and  whooping-cough  are  common  enough  clinically,  they  are,  rela¬ 
tively  speaking,  rarely  fatal.  Thus  they  have  not  seriously  affected  the  accuracy 
of  the  mortality  figures  for  these  two  diseases.  While  from  time  to  time,  from 
the  earliest  years,  a  few  deaths  have  been  classified  under  such  headings  as 
inflammation  of  the  throat  or  larynx,  tonsillitis,  and  cynanche  tonsillaris,  they 
were  never  sufficiently  numerous  to  warrant  special  consideration.  One  epi¬ 
demic  of  so-called  septic  sore  throat,  due  to  streptococcus  and  spread  largely 
by  the  milk  of  a  particular  dairy,  occurred  in  December  1911,  and  January, 
February,  and  March  1912.  According  to  conservative  estimates,  the  cases  must 
have  numbered  over  2,000.  The  deaths,  as  certified  under  a  variety  of  headings 
suggested  by  the  most  prominent  lesions,  such  as  appendicitis,  broncho-pneu¬ 
monia,  erysipelas,  and  peritonitis,  as  well  as  septic  sore  throat,  numbered  28. 


FEBRILE  DISEASES 


335 


The  two  remaining  members  of  this  group  have  rested  on  less  secure  ground. 
Though  possessing  leading  symptoms,  they  lack  absolutely  characteristic  symp¬ 
toms,  such  as  the  whoop  of  whooping-cough  and  the  loss  of  voice  and  the  pecu¬ 
liar  interference  with  breathing  of  typical  laryngeal  diphtheria.  Affecting 
organs  not  subject  to  direct  inspection  and  requiring  so  often  for  differential 
diagnosis  the  use  of  methods  of  physical  exploration  acquired  with  relative 
difficulty,  they  were  doubtless  frequently  mistaken  or  overlooked.  These 
methods,  percussion  and  auscultation,  though  perfected  by  Laennec  early  in  the 
nineteenth  century,  were  but  slowly  learned  with  precision  and  widely  adopted 
in  Baltimore.  It  is  doubtful  if,  until  William  Power’s  return  from  Paris  in 
1838,  there  was  a  single  adept  in  these  methods  in  the  city.  In  his  short  career, 
though  he  trained  the  talented  T.  H.  Buckler  and  the  band  of  bright  students 
who  gathered  around  them  at  the  almshouse,  he  could  not  have  trained  any 
large  proportion  of  the  medical  students  and  older  practitioners  of  his  day.  As 
late  as  1890  but  a  small  proportion  of  the  students  at  the  Baltimore  medical 
schools  had  the  opportunity  to  become  expert  in  the  use  of  these  methods.  The 
rest  picked  them  up  as  best  they  could.  It  was  not  until  well  after  1850  that  any 
large  proportion  of  the  practitioners  in  Baltimore  had  any  other  means  than 
those  afforded  by  common  clinical  symptoms,  such  as  chest  pain,  shortness  of 
breath,  fever,  and  the  character  of  the  respiration  and  expectoration  for  making 
differential  diagnoses  of  the  acute  diseases  of  the  bronchi,  lungs,  and  plurae. 
Hence  it  was  that  pleurisy  occupied  such  a  prominent  position,  that  broncho¬ 
pneumonia,  and  probably  bronchitis,  was  so  long  hid  in  catarrhal  fever,  and 
that  bronchitis  was  differentiated  so  late.  It  is  impossible  to  determine  whether 
the  terms  “  inflammation  of  the  bronchi  ”  and  “  inflammation  of  the  lungs  ” 
belonged  to  medical  nosology  or  were  simply  statistical  rubrics  of  the  health 
department,  designed  to  simplify  and  shorten  the  lists  of  the  causes  of  death. 

Bronchitis  alone  is  probably  rarely  fatal,  and  the  great  bulk  of  the  deaths 
attributed  to  it  must  surely  have  been  due  to  pneumonia,  usually  perhaps  to 
one  of  the  forms  of  broncho-pneumonia  in  the  pathological  anatomical  sense. 

Acute  pneumonia  or  acute  inflammation  of  the  lungs  (involving  often,  if  not 
usually,  the  adjacent  pleura)  is  not  a  single  and  specific  disease,  judged  either 
from  the  standpoint  of  the  portion  or  portions  of  the  lung  tissue  involved  or 
from  the  character  of  the  exudations  and  other  forms  of  inflammatory  lesions. 

Neither  bronchitis  nor  pneumonia  in  its  several  forms  is  specific  in  the  etio¬ 
logical  sense.  Both  are  caused  by  a  variety  of  bacteria — bacilli  and  cocci — and 
the  same  organism  does  not  always  give  rise  to  the  same  lesions.  Only  one  form 
of  pneumonia,  the  lobar  or  croupous,  seems  to  be  specific  in  the  etiological 
sense.  It  is  almost  if  not  always  associated  with  the  presence  in  the  affected 
portion  of  the  lung  of  a  particular  species  of  micro-organism,  the  pneumococ¬ 
cus.  At  least  four  different  varieties  of  the  pneumococcus  are  known,  and  these 
differ  among  themselves  not  only  in  frequency  of  ocurrence  in  pneumonia,  but 
in  virulence.  The  lethal  and  perhaps  the  invasive  capacity  of  each  type  is  by 
no  means  constant.  Again,  not  only  may  more  than  one  type  be  present  in  a 
particular  case  of  pneumonia,  but  bacteria  of  other  species  as  well.  Lobar 
pneumonia,  probably  usually  primary,  occurs  not  infrequently  as  a  complica¬ 
tion  of  other  diseases,  for  the  most  part  the  same  as  will  be  enumerated  for 
broncho-pneumonia. 


336  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

The  peculiar  type  of  lung  infection  characterized  by  lobar  consolidation  and 
simulating  lobar  pneumonia.,  but  due  to  B.  mucosus,  is  of  too  rare  occurrence 
to  be  statistically  important.  Bronchitis  and  broncho-pneumonia,  the  latter 
term  a  gather-all  for  several  distinct  types  of  lesions  having  in  common  the 
involvment  of  both  the  bronchial  and  lung  tissues,  may  be  caused  by  a  variety 
of  cocci  and  bacilli.  The  most  important  of  these  are  the  streptococci,  staphy¬ 
lococci,  pneumococci,  B.  mucosus,  and  B.  pfiefferi  (or  B.  influenza).  These 
and  others  may  be  present  alone  or  in  various  combinations.  While  broncho¬ 
pneumonia  occurs  very  commonly  as  a  complication  of  some  other  disease, 
acute  or  chronic,  it  is  not  infrequently  a  primary  disease.  The  most  common 
acute  diseases  which  it  complicates  are  the  so-called  exanthematous  diseases, 
particularly  measles  and  influenza,  whooping-cough,  diphtheria,  epidemic 
meningitis,  and  typhoid  and  typhus  fevers.  In  many  cases  of  wound  infection, 
including  puerpural  fever,  and  of  primary  suppurative  disorders,  as  appendi¬ 
citis  for  instance,  broncho-pneumonia  is  a  common  complication.  It  also  occurs 
in  such  specific  infections  as  glanders  and  anthrax,  but  usually  as  a  part  of 
the  disease.  Both  broncho  and  lobar  pneumonia  occur  as  terminal  events  in 
the  course  of  such  chronic  diseases  as  nephritis,  arteriosclerosis,  heart  disease, 
cirrhosis  of  the  liver,  diabetes,  tumor,  leucaemia,  and  the  like.  In  severe  acute 
malaria  pneumonia  often  occurred,  but  according  to  the  best  evidence  as  a 
complication.  Finally,  pathological  anatomists  have  shown  that  even  accom¬ 
plished  physicians  are  frequently  unable  to  distinguish  successfully  between 
broncho-pneumonia  and  lobar  pneumonia. 

A  very  strong  body  of  evidence,  drawn  from  both  clinical  observation  and 
laboratory  experiment,  indicates  that  all  of  these  affections  are  in  general  spread 
by  contact  from  person  to  person.  Opportunity  for  transfer  in  this  way  is 
abundant,  for  the  causative  agents  are  present  in  the  discharges  from  the  air- 
passages  and  in  the  mouths  and  noses  not  only  of  their  victims  during  illness, 
but  often  long  after  convalescence.  The  organisms  of  diphtheria  and  of  lobar 
pneumonia  have  often  been  isolated  from  the  mouths  and  throats  of  persons  who 
have  never  been  ill  with  these  diseases.  Indeed  this  “  healthy  carrier  99  state, 
common  enough  among  those  recently  exposed  to  persons  with  these  diseases, 
may  occur  in  individuals  who  have  never  consciously  been  so  associated.  Innu¬ 
merable  chances  occur  for  the  transfer  of  the  causes  of  all  these  affections  by 
kissing,  by  the  hands,  by  clothing,  by  utensils,  and  in  particular  by  coughing. 
While  it  is  doubtful  if  any  of  them  are  water-borne,  this  possibility  has  not 
been  excluded.  The  possibility  of  the  action  of  insects  as  mechanical  carriers 
at  certain  seasons  must  be  recognized.  Milk  has  been  shown  to  be  an  occasional 
vehicle  of  transfer  for  diphtheria  bacilli  and  streptococci.  All  the  evidence  at 
hand  tends  to  show  that  the  causative  agents  of  diphtheria,  whooping-cough, 
and  lobar  pneumonia  do  not,  under  ordinary  conditions  at  least,  long  survive 
separation  from  the  human  being  as  host.  Streptococci,  staphylococci,  and 
B.  mucosus  are  more  resistant  to  outside  influences,  and  in  consequence  have  a 
wide  range  of  distribution.  B.  pfieff  eri  does  not  apparently  long  survive  separa¬ 
tion  from  its  favorite  human  habitat.  These  diseases  must,  then,  be  classed  as 
contact  diseases  in  the  usually  accepted  sense. 


FEBRILE  DISEASES 


337 


WHOOPING-COUGH. 

Whooping-cough  appears  as  a  cause  of  death  in  the  mortality  records  for  1812 
and  is  credited  with  deaths  in  each  succeeding  year.  Endemically  intrenched 
when  the  present  record  begins,  it  has  maintained  this  position  uninterruptedly. 
Judged  from  the  wide  fluctuations  in  the  annual  mortality-rates  (table  60, 
graph  17),  its  lethal  capacity  in  relation  to  the  Baltimore  population  has  been 
marked  with  great  irregularity.  Its  highest  annual  death  rate,  215,  was  in 
1816,  and  the  highest  rates  subsequently  attained  were  in  1819,  1833,  1867, 
and  1877,  141,  140,  91,  and  95,  respectively.  Rates  between  60  and  70  occurred 
in  7  years  (1813,  1826,  1837,  1839,  1847,  1856,  and  1870),  between  50  and  60 


Graph  17  (from  table  60).  Annual  crude  mortality-rates  from  whooping- 
cough,  diphtheria,  and  pneumonia,  from  1812  to  1920,  inclusive. 


in  5  years  (1823,  1828,  1851,  1853,  and  1859),  and  between  40  and  50  in  15 
years  (1814,  1820,  1821,  1836,  1842,  1844,  1845,  1852,  1860,  1861,  1868,  1873, 
1874,  1880,  and  1918). 

Very  characteristic  of  its  course  has  been  the  occurrence  of  unusually  high 
death-rates  for  2  or  3  years  in  sequence,  followed  by  intermediate  periods  of 
low  rates  covering  one  or  even  several  years.  These  short  outbreaks  do  not, 
however,  follow  any  constant  law.  After  an  exceptionally  high  outbreak  in  one 
year,  particularly  if  it  be  preceded  by  a  year  or  two  of  low  rates,  the  succeeding 
drop  is  apt  to  be  correspondingly  low.  This  is  well  illustrated  in  1816,  1833, 
1905,  and  1918.  The  course  of  the  curve  is,  therefore,  very  irregular,  and  only 
rarely,  as  in  1843-1844,  1851-1855,  1858-1861,  1881-1883,  and  1890-1891, 
does  the  disease  exhibit  a  tendency  to  stabilize  about  a  fixed  level.  A  marked 


Table  60. — Number  oj  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from  whooping-cough,  diphtheria,  pneumonia,  bronchitis,  and  total 

acute  diseases  of  the  respiratory  tract,  and  percentage  of  total  deaths,  from  1812  to  1920,  inclusive. 


338  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


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FEBRILE  DISEASES 


339 


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340  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

decline  in  the  mortality-rates  began  about  1880,  but  the  persistence  of  con¬ 
siderable  annual  fluctuations  continued. 

The  curve  of  the  death-rates  averaged  for  5-year  periods  (table  61,  graph  18) 
shows  a  marked  rise  from  a  comparatively  low  rate  in  1812-1815  to  a  rate  of 
86  in  1816-1820,  with  a  sharp  fall  to  33  in  1821-1825.  For  the  next  25  years 
the  averaged  rates  change  but  little,  but  from  1851  to  1860  they  spring  to  about 
45,  followed,  however,  in  1861-1865,  by  a  sharp  fall  to  29.  Another  rise  in 
1866-1870  is  followed  by  a  decline  in  1871-1875  and  another  rise  in  1876- 
1880.  From  the  latter  date,  except  for  a  slight  ascent  in  1886-1890,  the  descent 
in  the  rates  is  sharp  to  the  low  rate  of  11  in  1896-1900.  During  the  last  20 


Table  61. — Average  rate  of  death  by  6-  and  10-year  periods  from  acute  diseases  of  the 

respiratory  tract,  from  1812  to  1920,  inclusive: 


Period. 

Pneumonia  and 
bronchitis. 

Whooping-cough. 

Diphtheria. 

Total. 

By  5-year 
periods. 

By  10-year 
periods. 

By  5-year 
periods. 

By  10-year 
periods. 

By  5-vear 

periods. 

By  10-year 

periods. 

By  5-year 

periods. 

By  10-year 

periods. 

1812-15  . 

193 

•  •  • 

39 

•  •  • 

86 

•  •  • 

318 

•  •  • 

1816-20  . 

132 

159  ' 

86 

65 

95 

91 

314 

316 

1821-25  . 

75 

•  •  • 

33 

•  •  • 

63 

•  •  • 

171 

•  •  • 

1826-30  . 

79 

77 

37 

35 

37 

50 

152 

162 

1831-35  . 

108 

•  •  • 

34 

•  •  • 

36 

•  •  • 

178 

•  •  • 

1836-40  . 

119 

113 

38 

36 

41 

39 

198 

188 

1841-45  . 

132 

... 

36 

... 

41 

•  •  • 

209 

... 

1846-50  . 

150 

141 

35 

35 

90 

65 

275 

242 

1851-55  . 

165 

•  •  • 

45 

•  •  • 

98 

•  •  • 

309 

•  •  • 

1856-60  . 

132 

149 

44 

45 

104 

101 

280 

294 

1861-65  . 

97 

•  •  • 

29 

•  •  • 

156 

•  •  • 

281 

•  •  • 

1866-70  . 

147 

122 

48 

38 

116 

136 

310 

296 

1871-75  . 

188 

•  •  • 

33 

•  •  • 

99 

•  •  • 

320 

•  •  • 

1876-80  . 

178 

183 

39 

36 

136 

117 

352 

336 

1881-85  . 

203 

•  •  • 

21 

•  •  • 

195 

•  •  • 

418 

•  •  • 

1886-90  . 

229 

216 

22 

22 

67 

131 

319 

368 

1891-95  . 

277 

•  •  • 

16 

... 

70 

•  •  • 

363 

•  •  • 

1896-1900  . 

267 

272 

11 

14 

66 

68 

343 

353 

1901-05  . 

263 

•  •  • 

11 

•  •  • 

26 

... 

300 

•  •  • 

1906-10  . 

224 

243 

15 

13 

14 

20 

253 

276 

1911-15  . 

222 

... 

8 

•  •  • 

14 

•  •  • 

244 

•  •  • 

1916-20  . 

305 

264 

13 

11 

13 

13 

332 

288 

years  the  rate  has  fluctuated  between  8  and  15.  When  the  rates  (table  61  and 
graph  19)  are  averaged  for  10-year  periods,  some  of  the  irregularities  above 
noted  are  eliminated  and  the  course  of  the  curve  is  somewhat  modified.  Starting 
in  1812-1820,  from  the  high  average  rate  of  65,  there  is  an  abrupt  drop  in 
1821-1830  to  35,  an  average  rate  about  maintained  the  next  20  years.  From 
the  average  rate  of  45  attained  in  1851-1860,  there  is  a  gradual  decline  to  36 
in  1871-1880  and  a  sharp  decline  to  14  in  1891-1900,  and  by  1911-1920,  the 
average  rate  was  11. 

These  curves,  obtained  by  averaging  the  annual  death-rates  by  5-  and  10-year 
periods,  give  essentially  the  same  picture  of  the  course  of  the  force  of  mortality 
of  whooping-cough  in  Baltimore  during  a  period  of  109  years.  Until  1825, 


FEBRILE  DISEASES 


341 


% 


Graph  18  (from  table  61).  Crude  mortality-rates  from  whooping-cough, 
diphtheria,  and  pneumonia,  averaged  by  5-year  periods,  from  1812  to  1920, 
inclusive. 


Graph  19  (from  table  61).  Crude  mortality-rates  from  whooping-cough, 
diphtheria,  and  pneumonia,  averaged  by  10-year  periods,  from  1812  to  1920, 
inclusive. 


342  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

perhaps  relatively  new  to  the  population,  this  disease  possessed  a  lethal  capacity 
of  a  high  order,  and  then  for  25  years  became  stabilized  at  a  much  lower  mor¬ 
tality-rate.  From  1850  to  1870  this  level  was  overshot,  but,  by  1875,  it  was 
again  reached.  Since  the  latter  date  the  average  rate  has  sunk  by  gradations 
to  a  level  lower  by  six  times  that  of  the  nine  years  1812-1820. 

The  influence  of  color,  sex,  and  age  upon  the  lethal  force  of  whooping-cough 
in  1910  and  1920  is  illustrated  in  tables  62  and  63.  From  these  it  is  clear  that 
the  disease  is  over  four  times  as  fatal  for  negroes  as  for  whites,  taking  the  two 


Table  62. — Number  of  deaths  and  the  rate  of  death,  per  100,000  living  inhabitants,  from 
whooping-cough  and  diphtheria,  according  to  age,  color,  and  sex,  for  1910. 

WHOOPING-COUGH. 


D  =  death.  R  =  rate. 


Total. 

White. 

Colored. 

Age-period. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

Under  1  year . 

43 

420 

30 

337 

18 

401 

12 

273 

13 

964 

8 

1168 

5 

754 

Between  1  and  2  yrs. 

15 

156 

9 

106 

1 

23 

8 

195 

6 

532 

4 

718 

2 

351 

2  to  4  years . 

20 

62 

7 

25 

1 

7 

6 

43 

13 

313 

4 

199 

9 

420 

5  to  9  years . 

4 

8 

1 

2 

1 

5 

•  •  • 

•  •  • 

3 

47 

2 

65 

1 

30 

Under  10  years . 

82 

81 

47 

53 

21 

47 

26 

59 

35 

268 

18 

285 

17 

252 

10  to  19  years . 

1 

1 

1 

7 

1 

17 

•  •  • 

•  •  • 

20  to  29  years . 

30  to  39  years . 

40  years  and  over . . . 

Total  . 

83 

15 

47 

10 

21 

9 

26 

11 

36 

42 

19 

48 

17 

37 

DIPHTHERIA. 


Under  1  year . 

4 

39 

3 

34 

2 

45 

1 

23 

1 

74 

1 

140 

•  •  • 

•  •  • 

Between  1  and  2  yrs. 

13 

135 

12 

141 

7 

160 

5 

122 

1 

89 

•  •  • 

•  ••  9 

1 

175 

2  to  4  years . 

31 

96 

31 

111 

19 

135 

12 

86 

5  to  9  years . 

11 

22 

11 

25 

3 

14 

8 

37 

Under  10  years . 

59 

58 

57 

64 

31 

69 

26 

59 

2 

15 

1 

16 

1 

15 

10  to  19  years . 

1 

1 

1 

1 

•  •  • 

•  •  • 

1 

2 

20  to  29  years . 

1 

1 

1 

5 

1 

11 

•  •  • 

... 

30  to  39  years . 

3 

3 

1 

1 

1 

3 

•  •  • 

•  •  • 

2 

13 

1 

13 

1 

12 

40  years  and  over . . . 

Total  . 

64 

11 

59 

12 

32 

14 

27 

11 

5 

6 

3 

8 

2 

4 

years  together,  somewhat  more  fatal  for  white  males  than  for  white  females, 
and  about  equally  fatal  for  males  and  females  among  negroes.  The  effect  of  age 
is  striking.  There  was  but  1  death  in  individuals  over  the  tenth  year  of  age,  and 
nearly  the  whole  mortality  was  confined  to  the  age  period  0  to  4  years,  and  over 
half  of  it  to  the  first  year  of  life.  The  experience  of  these  two  years  in  regard 
to  the  greater  mortality  in  negroes  as  compared  with  whites  is  confirmed  by  that 
of  the  16-year  period,  1905-1920,  when,  of  the  1,058  deaths  attributed  to 
whooping-cough,  598  were  in  whites  and  460  were  in  negroes,  a  ratio  of  1.3  to 
1,  while  the  proportion  of  whites  to  negroes  in  the  population  was  5.42  to  1. 


FEBRILE  DISEASES 


343 


On  the  assumption  that  throughout  the  course  of  the  disease  in  Baltimore  the 
fatality  in  whooping-cough  has  been  largely  if  not  entirely  restricted  to  the 
population  in  age-group  0-9  years,  mortality  rates  calculated  on  this  basis  for 
the  census  years  1830  to  1920,  inclusive,  should  be  instructive.  These  are  given 
in  table  64.  It  is  obvious  that  in  a  disease  whose  fatality  has  varied  so  greatly 
from  year  to  year,  the  rates  thus  obtained  for  these  particular  years,  even 
though  based  upon  the  averages  of  several  years,  can  not  be  taken  as  fully 
representative  of  the  respective  periods  in  which  they  lie.  But,  considered 

Table  63. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from 
whooping-cough  and  diphtheria,  according  to  age,  color,  and  sex,  for  1020. 


WHOOPING-COUGH. 
D  =  death.  R  =  rate. 


White. 

Colored. 

Age-groups. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

Under  1  year . 

34 

229 

18 

140 

9 

136 

9 

143 

16 

813 

6 

627 

10 

989 

1  to  4  years . 

20 

37 

13 

27 

8 

33 

5 

21 

7 

109 

3 

96 

4 

121 

0  to  4  years . 

54 

78 

31 

51 

17 

55 

14 

32 

23 

275 

9 

221 

14 

325 

5  to  9  years . 

2 

3 

1 

2 

1 

3 

•  •  • 

•  •  • 

1 

12 

•  •  • 

•  •  • 

1 

24 

0  to  9  years . 

56 

42 

32 

27 

18 

30 

14 

24 

24 

146 

9 

113 

15 

176 

10  to  19  years . 

20  to  29  years . 

30  to  39  years . 

40  years  and  over.... 

Total  . 

56 

8 

32 

5 

18 

6 

14 

4 

24 

22 

9 

17 

15 

27 

DIPHTHERIA. 


Under  1  year . 

10 

67 

10 

78 

5 

76 

5 

80 

1  to  4  years . 

72 

132 

68 

141 

30 

124 

38 

159 

4 

62 

3 

96 

1 

30 

0  to  4  years . 

82 

118 

78 

128 

35 

114 

43 

99 

4 

48 

3 

74 

1 

23 

5  to  9  years . 

15 

23 

15 

27 

9 

31 

6 

22 

0  to  9  years . 

97 

72 

83 

71 

44 

74 

49 

84 

4 

24 

3 

38 

1 

12 

10  to  19  years . 

20  to  29  years . 

2 

1 

2 

2 

•  •  • 

•  •  • 

2 

3 

30  to  39  years . 

1 

1 

1 

1 

1 

2 

40  years  and  over.... 

Total  . 

100 

14 

96 

15 

45 

14 

51 

16 

4 

4 

3 

6 

1 

2 

broadly,  these  rates  bring  out  more  clearly  the  relatively  high  mortality  that 
obtained  in  the  sixth,  seventh,  eighth,  and  ninth  decennia  of  the  nineteenth 
century,  the  subsequent  decline  from  this  high  level,  and  above  all  the  fact 
that  to  estimate  correctly  the  real  meaning  of  the  changes  observed  afterward 
in  the  course  of  the  crude  rates,  corrections  must  be  made  for  differences  which 
have  taken  place  in  the  age  distribution  of  the  population.  When  this  allowance 
is  made,  it  is  found  that  the  force  of  mortality  of  this  disease,  after  a  high 
accession  in  the  intermediate  period,  declined  by  1890  to  about  the  level  of 
1830,  from  which  it  has  departed  significantly  only  in  the  last  10  years. 


344  PUBLIC  HEALTH  ADMINISTRATION",  ETC.,  IN  BALTIMORE 

Data  for  morbidity  by  months  and  years  are  available  since  1897,  and  are 
presented  in  table  65.  All  the  evidence  at  hand  indicates  that  case  reporting  has 
never  approached  completeness.  The  testimony  of  health  wardens  of  long  experi¬ 
ence  is  that  many  cases  are  never  seen  by  physicians  and  that  a  physician 
called  to  see  the  first  case  in  a  family  of  children  often  does  not  see  and  report 
the  secondary  cases.  Cases  are  never  reported  by  parents  directly.  It  is  believed 
that  case  reporting  since  1910  has  reflected  the  actual  incidence  of  the  disease 
much  more  accurately  than  before  that  date.  There  is  no  evidence,  that  report¬ 
ing  was  more  accurate  between  1916  and  1920  than  it  was  between  1911  and 
1915.  Though  in  no  year  since  1897  do  the  recorded  figures  represent  actual 
occurrences,  relatively,  they  are  of  some  importance  for  determining  varia¬ 
tions  in  incidence  by  months  and  by  years.  In  the  24  years  under  review,  the 


Table  64. — Number  of  deaths  and  the  rate  of  death,  per 
100,000  living  inhabitants  under  10  years  of  age,  from 
whooping-cough  and  diphtheria,  for  the  decennia 
1830  to  1920,  inclusive* 


Year. 

Whooping-cough. 

Diphtheria. 

Deaths. 

Rate. 

Deaths. 

Rate. 

1830  . 

17 

82 

23 

Ill 

1840  . 

39 

146 

36 

135 

1850  . 

55 

123 

148 

332 

1860  . 

106 

189 

238 

424 

1870  . 

96 

147 

273 

419 

1880  . 

107 

144 

611 

812 

1890  . 

88 

96 

307 

336 

1900  . 

43 

42 

253 

249 

1910  . 

86 

85 

69 

68 

1920  . 

40 

30 

123 

92 

*  The  number  of  deaths  for  each  decennium  is  a  3- 
year  average  of  that  obtaining  in  the  decennial  year  and 
in  those  years  immediately  preceding  and  following, 
except  in  1920,  when  the  average  is  for  1919  and  1920  only. 


rates  of  incidence  have  varied  considerably  from  year  to  year  and  have  shown 
a  wide  margin  between  the  highest  and  the  lowest  levels  attained.  Conspicuous 
examples  of  such  deviations  in  the  rates  were,  in  the  earlier  period,  15  in  1904 
and  120  in  1909,  and  in  the  later  period,  42  in  1915  and  508  in  1920.  The 
rates  averaged  for  5-year  periods  were  46  and  47,  respectively,  for  1897-1900 
and  1901-1905,  75  for  1906-1910,  62  for  1911-1915,  and  237  for  1916-1920. 
The  annual  rates  averaged  for  the  10-year  periods  1901-1910  and  1911-1920 
were  61  and  149,  respectively.  The  increase  in  recorded  incidence  of  the  disease 
since  1916  is  particularly  striking.  It  will  be  noted  that  after  two  years  of 
exceptionally  high  rates,  230  and  209,  respectively,  the  former  the  highest  ever 
recorded  up  to  that  time,  the  rate  in  1918  jumped  to  508.  Falling  to  91  in 
1919,  the  morbidity-rate  rose  to  148  in  1920.  While  the  general  increase  in 
the  morbidity-rates  since  1910  was  doubtless  in  some  measure  due  to  more 
complete  case  reporting  in  this  period  as  compared  with  the  years  previous  to 
this  date,  the  wide  annual  fluctuations  characteristic  of  both  periods  can  not  be 


FEBRILE  DISEASES 


345 


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346 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


so  explained.  Whatever  the  actual  and  the  relative  values  of  the  rates  previous 
to  1910,  the  evidence  at  hand  indicates  that  at  least  the  major  part  of  the 
increase  in  the  rates  between  1916  and  1920,  as  compared  with  the  period  1911- 
1915,  was  due  to  a  real  rise  in  incidence,  and  not  alone  to  fuller  case  reporting. 


Table  66  —Number  of  cases  and  the  rate  of  morbidity,  per  100,000  living  inhabitants  in  1920, 
for  whooping-cough  and  diphtheria,  according  to  age,  sex,  and  color,  for  1921. 

WHOOPING  COUGH. 


O  --  cases.  R  —  rate. 


Age-groups. 

Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem, 

C 

R 

C 

R 

C 

R 

C 

R 

C 

R 

C 

R 

c 

R 

Under  1  year. 

396 

2666 

349 

2709 

196 

2970 

153 

2435 

47 

2388 

22 

2299 

25 

2473 

1  to  4  years 

1444 

2649 

1381 

2871 

669 

2771 

712 

2973 

63 

983 

28 

899 

35 

1063 

0  to  4  years 

1840 

2653 

1730 

2837 

865 

2813 

865 

1996 

110 

1313 

50 

1229 

60 

1394 

5  to  9  years 

1265 

1961 

1205 

2136 

589 

2061 

616 

2213 

60 

744 

25 

648 

35 

832 

0  to  9  years 

3105 

2320 

2935 

2500 

1454 

2451 

1481 

2560 

170 

1034 

75 

946 

95 

1116 

10  to  19  years 

142 

115 

126 

117 

63 

119 

63 

115 

16 

100 

8 

113 

8 

90 

20  to  29  years 

8 

6 

8 

7 

8 

13 

30  to  39  years 

12 

10 

12 

12 

6 

12 

6 

12 

40  to  49  years 

2 

2 

2 

3 

1 

3 

1 

3 

50  to  59  years 

60  to  69  years 

70  to  79  years 

2 

13 

2 

15 

2 

27 

80  years  and 

over  . 

Total  . . . 

3271 

446 

3085 

493 

1524 

494 

1561 

493 

186 

171 

83 

156 

103 

186 

DIPHTHERIA. 


Under  1  year. 

48 

323 

38 

295 

21 

318 

17 

271 

10 

508 

2 

209 

8 

791 

1  to  4  years 

554 

1016 

537 

1116 

291 

1205 

246 

1027 

17 

265 

13 

418 

4 

121 

0  to  4  years 

602 

868 

575 

943 

312 

1015 

263 

607 

27 

322 

15 

369 

12 

279 

5  to  9  years 

508 

788 

493 

874 

266 

931 

227 

815 

15 

186 

10 

259 

5 

119 

0  to  9  years 

1110 

8293 

1068 

910 

578 

974 

490 

844 

42 

255 

25 

315 

17 

200 

10  to  19  years 

185 

150 

174 

161 

84 

159 

90 

164 

11 

69 

5 

71 

6 

68 

20  to  29  years 

75 

52 

72 

60 

23 

39 

49 

81 

3 

11 

•  •  •  • 

•  •  •  • 

3 

22 

30  to  39  years 

38 

31 

36 

36 

9 

18 

27 

54 

2 

9 

•  •  •  • 

•  •  •  • 

2 

19 

40  to  49  years 
50  to  59  years 
60  to  69  years 
70  to  79  years 
80  years  and 

8 

9 

8 

10 

3 

8 

5 

13 

5 

8 

5 

9 

1 

4 

4 

14 

1 

3 

1 

3 

1 

6 

1 

7 

1 

8 

1 

18 

over  . 

Total  . . . 

1423 

194 

1365 

218 

699 

227 

666 

210 

58 

53 

30 

56 

28 

50 

From  table  66  it  appears  that,  so  far  as  may  be  judged  from  the  reported  cases 
in  1921,  the  incidence  of  whooping-cough  was  confined  almost  entirely  to  indi¬ 
viduals  under  the  tenth  year.  The  attack-rate  was  notably  high  under  1  year 
of  age,  and  higher  in  the  first  than  in  the  second  5  years  of  life.  Morbidity  was 
much  greater  among  whites  than  among  negroes,  and  somewhat  greater  among 
females  than  among  males  in  the  black  race. 


FEBRILE  DISEASES 


347 


Kates  for  case  fatality  are,  of  course,  open  to  the  same  criticism  as  those  for 
morbidity.  Extreme  examples  of  these  variations  are  3  per  cent  in  1919  and 
32  per  cent  in  1906.  They  have  by  no  means  risen  and  fallen  directly  with 
the  morbidity-rates,  for  whereas,  lower  case-fatality  rates  have  often  synchro¬ 
nized  with  higher  morbidity-rates,  the  reverse  has  also  frequently  occurred 
(table  65).  As  averaged  for  5-year  periods  from  1901  to  1920,  the  case-fatality 
rates  were  26,  19,  13,  and  5  per  cent,  respectively.  Has  whooping-cough  in 
the  last  15  years,  as  the  official  figures  seem  to  show,  become  more  prevalent 
and  relatively  less  lethal,  or,  otherwise  expressed,  has  a  greater  increase  in 
invasive  capacity  been  associated  with  a  corresponding  decrease  in  mortality 
force  ?  It  has  been  shown  that  differences  in  accuracy  of  case  reporting  can  not 
be  held  responsible  for  all  of  the  variations  in  morbidity.  There  were  no  marked 
differences  in  the  age,  sex,  and  race  distributions  of  the  population.  Light  may 
be  thrown  upon  this  point  by  the  experience  of  earlier  years.  From  1812  to 
1815  there  were  67  deaths  recorded  from  whooping  cough  in  an  average  popu¬ 
lation  of  about  45,000,  and  on  a  basis  of  a  case-fatality  rate  of  5  per  cent  (as 
apparently  obtained  on  an  average  between  1916  and  1920)  there  would  have 
been  1,340  cases,  a  total  case  incidence  of  about  3,000  per  100,000,  or  an  aver¬ 
age  of  750  per  100,000  per  annum.  But  in  a  single  year,  1816,  immediately 
following  this  period,  there  were  105  deaths  in  a  population  of  about  48,000, 
which  on  the  same  ratio  would  mean  2,100  cases,  or  an  incidence  rate  of  4,375 
per  100,000.  Accordingly,  in  the  5  years  there  would  have  been  3,440  cases,  a 
number  equal  to  at  least  a  fourth  of  the  number  of  living  children  under  10 
years  of  age  in  the  population.  Therefore,  unless  the  disease  was  much  more 
common  in  the  higher  ages  than  has  recently  obtained,  no  such  attack-rate 
would  have  been  likely.  On  the  whole,  therefore,  it  would  appear  that  during 
the  20-year  period  1901-1920  the  morbidity-rates  were  constantly  rising  and 
the  case-fatality  rates  were  falling. 

From  the  curves  of  the  monthly  annual  mortality  and  morbidity  rates  (tables 
65  and  67)  it  is  evident  that  whooping-cough  has,  as  a  general  rule,  in¬ 
creased  in  both  mortality  and  in  incidence  in  spring  and  early  summer 
months  and  often  reaching,  or  at  least  maintaining,  the  highest  levels  in  mid¬ 
summer.  The  lowest  rates  have  very  commonly  fallen  in  the  late  summer  and 
fall.  Months  in  which  the  maximum  mortality  has  occurred  during  the  65 
years,  1856-1920,  inclusive,  as  expressed  in  percentages  of  the  total  number  of 
years  (table  68)  were,  August  23,  July  17,  September  14,  January  9,  February 
and  June,  each,  8,  March  6,  April  and  October,  each,  5,  November  3,  and  May 
and  December,  each,  2.  Months  of  highest  incidence,  for  the  24  years  1897- 
1920,  inclusive,  similarly  expressed  (table  68),  were,  February  25,  December 
and  July,  each,  17,  April,  May,  and  August,  each,  8,  January,  March,  June, 
and  November,  each,  4.  On  the  same  basis  of  calculation,  months  of  lowest 
incidence  were,  December  29,  February  and  October,  each,  17,  March  13,  May 
and  September,  each,  8,  January  and  July,  each,  4.  In  no  years  did  the  highest 
incidence  fall  in  September  or  October,  or  the  lowest  incidence  occur  in  April, 
June,  August,  or  November. 

With  the  exception  of  such  exclusion  from  school  of  children  with  whooping- 
cough  as  may  have  been  exercised  by  the  school  authorities,  no  administrative 
measures  were  applied  to  restrict  the  spread  of  whooping-cough  until  1916. 

23 


Table  67. — Mortality  by  months  and  years  and  monthly  annual  and  annual  mortality  rates,  per  100,000  living  inhabitants,  from  whooping-cough, 

from  1856  to  1920,  inclusive. 


4 


348  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


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FEBRILE  DISEASES 


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350  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

Since  this  date  recognized  cases  of  the  disease  have  been  kept  out  of  school,  but 
placarding  houses  with  warning  signs  has  been  ineffective  in  keeping  persons 
out  of  infected  households  and  patients  from  associating  with  other  children  on 
the  streets  and  elsewhere. 


Table  68. — Maximum  incidence  oj  mortality  and  maximum  and  minimum  incidence  of 
morbidity  from  whooping-cough,  by  months,  from  1856  to  1920,  inclusive,  and  from 
1897  to  1920,  inclusive,  respectively ,  and  the  percentage  of  each  to  total  number  of 
years. 


Months. 

Months  in  65  years 
in  which 

maximum  mortality- 
rate  obtains. 

Months  in  24  years 
in  which 

maximum  morbidity- 
rate  obtains. 

Months  in  24  years 
in  which 

minimum  morbidity- 
rate  obtains. 

No. 

Percentage  to 
total  years. 

No. 

Percentage  to 
total  years. 

No. 

Percentage  to 
total  years. 

Jan . 

6 

9 

1 

4 

1 

4 

Feb . 

5 

8 

6 

25 

4 

17 

Mar . 

4 

6 

1 

4 

3 

13 

Apr . 

3 

5 

2 

8 

•  •  • 

•  •  • 

May  . 

1 

2 

2 

8 

2 

8 

June  . 

5 

8 

1 

4 

•  •  • 

•  •  • 

J  uly  . 

11 

17 

4 

17 

1 

4 

Aug . 

15 

23 

2 

8 

.  .  • 

•  •  • 

Sept . 

9 

14 

•  •  • 

•  •  • 

2 

8 

Oct . 

3 

5 

•  •  • 

... 

4 

17 

Nov . 

2 

3 

1 

4 

•  •  • 

•  •  • 

Dec . 

1 

2 

4 

17 

7 

29 

Total  . 

65 

100 

24 

100 

24 

100 

DIPHTHERIA  AND  “  MEMBRANOUS  ”  OR  TRUE  CROUP. 

Local  chronicles  are  strangely  silent  on  the  subject  of  this  ancient  disease 
described  under  many  different  names,  which  were  gradually  displaced  by  the 
term  diphtheria  given  it  by  Bretonneau  in  1821.  It  is  not  known  whether 
the  serious  epidemic  in  New  York  City  in  the  latter  part  of  the  eighteenth 
century,  described  so  well  by  Dr.  Samuel  Bard  as  angina  suffocativa  or  sore- 
throat  distemper  and  later  identified  with  diphtheria,  reached  Baltimore. 
Croup  and  membranous  croup  were  credited  with  a  considerable  number  of 
deaths  in  1812  and  each  year  thereafter  until  1898.  Charles  Frick  (4?)  in 
1855  included  them  among  the  “  zymotic  93  diseases.  The  term  diphtheria  did 
not  appear  in  the  local  statistical  nosology  until  1860,  when  it  was  credited 
with  7  deaths,  in  contrast  to  293  for  membranous  croup.  By  1863  the  propor¬ 
tion  was  162  to  294,  in  1872  it  was  100  to  162,  and  not  until  1887  was  it 
the  same.  In  the  course  of  the  next  decade,  croup  or  membranous  croup  gradu¬ 
ally  gave  place  in  usage,  and  by  1898  it  had  become  a  subheading  under 
diphtheria.  It  will  be  noted  that  diphtheria  did  not  appear  in  the  causes  of 
death  until  two  years  after  the  beginning  of  the  epidemic  visitation  in  1858. 
The  number  of  deaths  ascribed  to  sore  throat,  cynanche  tonsillaris,  angina, 
and  inflammation  of  the  throat  was  too  small  to  have  embraced  deaths  from 


FEBRILE  DISEASES 


351 


typical  faucial  diphtheria  if  the  latter  had  been  at  all  frequent  and  fatal  before 
this  date. 

For  any  proper  estimation  of  the  real  relation  of  true  or  membranous  croup 
to  diphtheria  in  Baltimore,  it  is  necessary  briefly  to  review  opinions  held  con¬ 
cerning  their  identity  during  the  period  under  consideration.  Home  (61),  of 
Edinburgh,  who  gave  a  good  description  of  croup  in  1765,  regarded  it  as  a 
primary  disease  occurring  independent  of  a  previous  angina.  Bard  (62), 
writing  in  1789,  regarded  croup  and  epidemic  angina  as  the  same  disease. 
Bretonneau,  1821,  1825,  and  1826,  was  the  first  to  recognize  that  the  nasal, 
faucial,  laryngeal,  ocular,  cutaneous,  and  genital  false-membranous  lesions 
were  all  manifestations  of  a  specific  local  inflammation.  His  view  of  the  identity 
of  croup  and  diphtheria  was  widely  accepted,  particularly  in  France.  It  was 
disputed,  however,  especially  in  Germany,  under  the  leadership  of  Virchow. 
The  great  French  clinician  Trousseau,  while  in  general  agreeing  with  Breton- 
neaffis  views,  impressed  upon  many  his  own  opinion  that  diphtheria  was  a 
general,  and  not  primarily  a  local,  affection.  The  correctness  of  Bretonneau’s 
teachings  were  demonstrated  finally  by  Boux  and  Yersin  in  1888-1890,  in 
their  experimental  investigations  on  B.  diphtheria  described  by  Klebs  in  1883 
and  cultivated  by  Loeffler  in  1884.  The  mass  of  clinical  and  laboratory  investi¬ 
gations  since  the  development  of  the  antitoxin  treatment  in  1894  and  of  the 
diphtheria  culture  test  in  1896  have  further  confirmed  them. 

The  manuscript  lectures  of  William  T.  Howard,  sr.  (56),  written  about 
1867  and  illustrated  with  his  views  of  personally  observed  cases,  throw  valuable 
light  upon  the  characteristics  of  membranous  croup  and  diphtheria  in  Balti¬ 
more  and  the  views  locally  current  concerning  them  at  that  time.  His  descrip¬ 
tion  of  primary  faucial  diphtheria,  with  or  without  involvement  of  the  nares, 
larynx,  conjunctiva,  esophagus,  skin,  and  genitals,  was  in  general  agreement 
with  those  of  Bretonneau  and  other  French  authors  and  of  leading  contempo¬ 
rary  writers  of  England,  Hew  York,  and  Philadelphia.  However,  on  account  of 
the  profound  intoxication  which  characterized  it,  he,  in  opposition  to  Breton¬ 
neau,  held  diphtheria  to  be  primarily  a  general  systemic  disease,  to  which  the 
cyanosis,  purpura,  cardiac  embarrassment,  convulsions,  coma,  and  paralysis, 
as  well  as  the  swelling  of  the  lymph-glands  and  the  inflammatory  processes  of 
the  fauces,  nares,  larynx,  esophagus,  and  other  organs  were  all  secondary.  Of 
croup  he  recognized  three  types :  The  spasmodic  or  false  croup  without  false 
membrane  and  rarely  fatal,  membranous  or  true  croup,  and  diphtheritic  croup. 
The  latter  was  regarded  as  a  fortuitous  complication  of  true  diphtheria.  Mem¬ 
branous  or  true  croup,  though  the  false  membrane  in  the  larynx  and  certain 
clinical  symptoms  were  identical  with  those  of  diphtheritic  croup,  he  held, 
in  opposition  to  the  French  writers,  to  be  a  separate  and  distinct  disease. 
Attacking  young  children  and  insidious  in  its  onset  and  course,  it  was  unat¬ 
tended  by  high  fever,  prostration,  and  other  symptoms  of  intoxication.  Hoarse¬ 
ness,  gradual  loss  of  voice,  progressive  difficulty  in  breathing,  ending  usually 
in  suffocation  from  mechanical  closure  of  the  larynx,  were  the  cardinal  symp¬ 
toms.  The  mind  was  unaffected  till  near  the  end,  and  the  coma,  hemorrhages, 
and  swellings  of  cervical  lymph-glands,  so  characteristic  of  diphtheria,  were 
absent.  Nor  did  those  who  escaped  death  by  suffocation  develop  paralysis,  so 
frequent  in  diphtheria.  The  inflammatory  process  did  not,  as  was  the  case  with 
diphtheritic  croup,  involve  other  organs  than  the  larynx.  Membranous  croup, 


352  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

unlike  diphtheria,  was  a  sporadic  disease,  never  epidemic,  and  affected  a 
single  child  in  a  family  or  neighborhood.  “  Until  within  a  very  few  years  past 
(since  1858)  no  living  American  physician  had  seen  a  genuine  widespread 
epidemic  of  diphtheria,  and  yet  all  had  ever  been  familiar  with  membranous 
croup.” 

This  primary  membranous  croup  was  common  enough,  and  unless  trache¬ 
otomy  was  performed  was  fatal  in  90  per  cent  of  the  cases.  Such,  then,  must 
have  been  the  characteristics  of  the  membranous  croup  held  responsible  for 
such  high  mortality  from  1812  until  long  after  1870.  In  reply  to  the  question, 
was  this  diphtheria,  it  may  be  said  that  some  years  later  (before  1880  at  least), 
with  larger  experience,  Dr.  Howard  changed  his  opinion  and  taught  that  mem¬ 
branous  croup  and  diphtheritic  croup  were  and  had  always  been  the  same 
disease,  and  that  the  confusion  had  been  due  to  differences  in  the  character  of 
diphtheria  before  and  after  the  epidemic  invasion  of  1858.  About  1885  it 
became  generally  recognized  in  Baltimore  that  diphtheria  might  be  primary  in 
the  nose,  throat,  larynx,  or  elsewhere  and  remain  confined  to  the  original  seat, 
or  descend  or  ascend  as  the  case  might  be,  and  that  contact  with  a  case  of 
primary  laryngeal  diphtheria,  or  true  croup,  was  often  followed  by  the  develop¬ 
ment  of  faucial  diphtheria  in  persons  so  exposed,  and  vice  versa.  Welch’s  illu¬ 
minating  address  on  the  causation  of  diphtheria  before  the  Medical  and  Chi- 
rurgical  Faculty  in  1891  dispelled  lingering  doubts  in  the  minds  of  Baltimore 
physicians  and  convinced  them  of  the  unity  of  faucial  diphtheria  and  membra¬ 
nous  croup  under  the  causal  agency  of  B.  diphtheria. 

In  the  light  of  the  foregoing  considerations,  it  seems  reasonably  certain  that 
the  deaths  accredited  to  croup  and  membranous  croup  in  the  local  statistical 
nosology  since  1812  belong  to  the  category  of  laryngeal  diphtheria,  with  or 
without  involvement  of  other  structures,  and  that  the  whole  number  of  deaths 
assigned  to  this  rubric  and  to  diphtheria  probably  fall  short  of  the  whole 
number.  Some  deaths  due  to  diphtheria  were  probably  classified  under  com¬ 
plicating  affections,  and  there  was  doubtless  some  confusion  with  scarlet  fever, 
particularly  when  the  two  diseases  were  at  the  height  of  their  careers. 

From  table  60  and  graph  17  the  course  of  diphtheria,  as  determined  by  annual 
mortality-rates,  may  be  followed  through  109  years.  In  the  curve  of  mortality 
as  expressed  in  annual  rates  at  least  six  separate  and  well-defined  waves  appear : 
(1)  1812-1831,  (2)  1832-1841,  (3)  1842-1875,  (4)  1876-1890,  (5)  1891- 
1893,  (6)  1894-1908.  Since  the  latter  date  the  disease  has,  except  for  a  sudden 
rise  in  1919,  run  a  course  fairly  stable.  During  the  first  period,  covering  19 
years,  the  annual  rates  were  relatively  high,  and  in  4  years  surpassed  100. 
The  second  wave,  extending  over  10  years,  was  considerably  lower,  with  54  as 
the  highest  annual  rate.  The  third  wave,  covering  33  years,  reached  and  main¬ 
tained  a  relatively  high  level,  with  rates  over  100  in  16  years  and  between  80 
and  100  in  10  years.  In  the  fourth  wave,  embracing  14  years,  occurred  the 
highest  annual  rates  attained,  over  200  in  3  years  (255  in  1881,  263,  in  1882, 
and  220  in  1883),  and  over  100  in  6  other  years.  In  the  fifth  wave,  covering 
4  years,  the  highest  rate  was  97.  The  long  final  wave  with  its  peak  in  1898, 
with  a  rate  of  80,  tailed  off  very  gradually.  Nearly  all  these  waves  are  charac¬ 
terized  by  minor  elevations  and  depressions,  which  break  the  smoothness  of  their 
curves.  It  will  be  noted  that  the  third  and  longest  wave  had  reached  a  relatively 
high  level  (but  no  higher  than  the  highest  point  attained  by  the  first  wave) 


FEBRILE  DISEASES 


353 


before  1860,  when  the  term  diphtheria  came  into  the  statistical  nosology. 
However,  as  above  indicated,  during  the  years  immediately  following  1860, 
a  relatively  large  proportion  of  the  deaths  in  this  group  were  still  classified 
under  croup. 

Viewed  from  another  angle,  namely,  by  comparing  the  average  annual  death- 
rates  for  5-year  periods  from  1815  to  1920,  it  appears  very  clearly  (table  61 
and  graph  18)  that  the  period  under  observation  begins  with  the  end  of  the  crest 
of  a  long  wave  of  relatively  high  mortality,  only  9  years  of  which,  1812-1820, 
come  under  view,  with  a  sharp  decline  during  the  next  10  years,  1820-1830. 
From  this  point  begins  the  second  wave  the  whole  extent  of  which  is  in  view. 
Rising  very  gradually  between  1835  and  1840,  and  remaining  stationary  during 
the  next  5  years,  the  ascent  is  first  rapid  and  then  again  gradual  to  a  peak 
reached  in  1861-1865.  From  this,  after  a  second  recession  occupying  a  10-year 
period,  the  ascent  is  resumed  to  a  second  peak  in  1881-1885.  The  5-year  period 
ending  in  1885  marks  the  acme;  never  before  was  its  lethal  power  so  great. 
During  the  following  5  years  there  is  an  abrupt  decline  from  195  to  67,  a  point 
maintained  with  but  slight  variation  for  10  years,  1890-1900.  The  mortality- 
rates  as  averaged  for  10-year  periods  (table  61,  graph  19)  fell  continuously 
and  sharply  from  91  in  1812-1820  to  39  in  1830-1840.  During  the  succeeding 
30  years  they  ascended  steadily  and  by  equal  steps  to  a  peak  with  a  rate  of  136 
in  1860-1870.  Falling  slightly  in  the  next  10-year  period,  the  rates  had  reached 
131  by  1880-1890.  From  this  point  they  fell  precipitately  to  68  in  1890-1900, 
or  to  about  the  level  attained  in  1840-1850.  This  remarkable  tidal-wave  of 
mortality  rose  through  a  period  of  30  years  to  a  crest,  which,  though  broken 
was  held  for  20  }^ears  and  then  fell  in  10  years  by  two-thirds  of  its  rise.  The 
descent  in  the  rates  during  the  20-year  period  after  1901,  to  the  low  level  of  13 
occurred  under  altered  conditions.  Since,  as  will  be  shown  later,  almost  the 
whole  of  the  mortality  from  diphtheria  occurs  in  individuals  under  the  tenth 
year,  rates  specific  for  this  age-group  for  the  census  years  1830  to  1920,  inclu¬ 
sive,  which  are  presented  in  table  64  may  be  studied  with  profit.  While  the 
rates  for  these  selected  years  represent,  for  the  most  part,  by  no  means  the 
peak-rates  of  the  corresponding  periods,  they  illustrate  fairly  accurately  the 
rise  in  mortality  from  about  1850  to  the  climax  in  the  ninth  decade  of  the 
last  century,  the  subsequent  gradual  decline  in  the  preantitoxin  days  and  the 
conspicuous  drop  after  1900.  It  is  evident  that  changes  in  the  proportion  of 
this  age-group  in  the  population  in  the  last  20  years  has  been  too  slight  to 
have  exerted  any  important  influence  upon  this  decline. 

In  spite  of  the  evidence  that  diphtheria  never  appeared  in  epidemic  outbreaks 
in  Baltimore  before  1858  and  that  in  its  prevalent  form  as  membranous  croup 
up  to  that  date  it  appeared  only  sporadically  and  was  not  evidently  spread  from 
one  person  to  another  by  personal  contact,  it  was  nevertheless  responsible  for 
relatively  high  death-rates  between  1812  and  1823  and  between  1847  and  1858. 
Indeed,  it  was  only  between  1859  and  1868  and  between  1877  and  1883  that 
the  rates  conspicuously  surpassed  those  that  often  obtained  before  1858. 

The  data  from  which  morbidity  and  case  fatality  in  diphtheria  may  be 
studied  date  from  1893,  the  year  in  which  the  mortality-rate  fell  to  the  lowest 
level  since  1881.  Since  in  this  and  the  3  succeeding  years  the  cases  were 
reported  so  inadequately  and  their  monthly  distribution  was  not  recorded,  the 
reported  cases  for  this  period  have  not  been  included  in  the  regular  tables. 


354  PUBLIC  HEALTH  ADMINISTRATION-,  ETC.,  IN  BALTIMORE 

For  these  4  years  the  absolute  and  relative  figures  for  mortality  and  case 
fatality  were  as  presented  in  table  69. 

From  these  figures  with  continuously  rising  morbidity-rates  (and  except  in 
1896  rising  mortality-rates  also),  which  were  considerably  lower  than  ever  again 
achieved  (except  in  1909  and  1910)  and  associated  with  steadily  falling  case- 
fatality  rates,  it  is  clear  that  comparison  with  later  years  is  not  warranted. 
In  the  first  two  of  these  years  antitoxin  was  not  available,  and  during  the  last 
two  it  could  not  have  been  very  widely  used.  It  is  particularly  to  be  noted  that 
the  above  case-fatality  rates  can  not  with  justice  be  taken  as  criteria  for  com¬ 
parison  with  rates  during  the  antitoxin  period. 


Table  69. 


Year. 

Cases. 

Morbidity -rate 
per  100,000. 

Deaths. 

Per  cent 
case 
fatality. 

1893  .... 

346 

76 

210 

60.7 

1894  .... 

409 

88 

231 

56.5 

1895  .... 

629 

133 

310 

49.3 

1896  .... 

653 

136 

280 

42.9 

Turning  to  tables  70  and  71,  it  will  be  observed  that  there  is  a  close  corre¬ 
spondence  between  the  course  of  the  curves  for  mortality  and  morbidity  since 
1897.  After  a  steady  fall  in  both  until  1910,  they  were  subject  to  an  upward 
wave  during  the  next  3  years,  from  which  there  was  a  descent  to  the  lowest 
points  reached  in  the  former  in  1918  and  in  the  latter  in  1917.  They  rose 
together  and  markedly  in  1919  and  descended  in  1920.  From  this  close  corre¬ 
spondence  it  would  appear  that  the  cases  during  this  time  have  been  reported 
with  a  fair  degree  of  accuracy  and  evenness,  and  that  the  courses  of  morbidity 
and  mortality  must  have  been  influenced  by  causes  acting  at  the  same  time 
and  on  the  whole  with  very  much  the  same  degree  of  force. 

It  is  evident  that  the  medical  and  administrative  agencies  that  have  tended 
to  reduce  the  death-rate  (more  accurate  and  earlier  diagnosis,  antitoxin  treat¬ 
ment,  and  the  extension  of  the  use  of  intubation)  have  not  seriously  influenced 
case  incidence;  for  every  case  saved  from  death,  until  the  augmentation  of  the 
restrictive  measures  after  1910,  and  especially  after  1915,  meant  a  potential 
carrier  to  spread  the  disease  and  thus  to  increase  the  incidence  rate.  While  there 
was  a  considerable  fall  in  incidence  in  1916,  1917,  and  1918,  after  the  imposi¬ 
tion  of  much  more  restrictive  measures  than  had  before  obtained,  with  special 
emphasis  on  the  use  of  the  culture  method  to  govern  the  control  of  convalescents 
and  carriers,  the  morbidity-rates  surpassed  those  of  1913,  1914,  and  1915. 
As  a  matter  of  fact,  the  average  morbidity  rate  for  the  5-year  period  ending 
in  1920  is  scarcely  lower  than  that  ending  in  1910,  156  and  159,  respectively. 

From  the  average  morbidity-rates  for  the  5-year  periods  (table  71)  it  is 
clear  that,  on  the  whole,  the  more  intensive  efforts  to  curtail  diphtheria  during 
the  last  5  years  were  associated  with  results  no  better  than  during  the  5  years 
ending  in  1910.  In  so  far  as  these  data  justify  conclusions,  it  may  be  said  that 
under  the  conditions  obtaining  in  Baltimore  the  invasive  capacity  of  diph¬ 
theria  is  inconstant,  that  the  course  of  morbidity  preserves  its  tendency  to  run 


FEBRILE  DISEASES 


355 


in  waves,  and  that  restrictive  measures  as  applied  exert,  on  the  whole,  but 
comparatively  little  influence  upon  the  relative  incidence  of  the  disease  over  a 
considerable  term  of  years.  In  1919  and  1920  the  incidence  of  the  disease 
relative  to  the  population  was  very  much  the  same  as  in  1901,  1913,  and  1914. 
It  may  be  argued,  perhaps  with  justice,  that  the  waves  noted  would  have  reached 
higher  levels  but  for  the  interferences  interposed  by  publicly  and  privately 
directed  activities.  So  far  as  may  be  judged  from  the  experiences  of  1921, 
the  only  year  for  which  the  necessary  data  are  available,  morbidity  from  diph¬ 
theria  has  been  profoundly  influenced  by  age,  color,  and  sex.  Rates  specific  for 
these  categories  for  this  year  are  given  in  table  GO.  While  the  disease  occurred 
in  every  decade  of  life  up  to  the  ninth,  approximately  three-fourths  of  the 
cases  were  in  individuals  under  the  tenth  year  of  age.  Considering  this  age- 
group  first,  it  will  be  noted  that  the  rates  were  higher  in  the  first  than  in  the 
second  5  years  of  life  and  that  the  incidence  was  particularly  high  in  the  first 
year.  From  the  tenth  year  on,  the  rate  of  incidence  decreased  through  the 
decades  in  regular  order,  with  the  exception  that  the  rate  was  higher  in  the 
eighth  than  in  the  seventh.  In  respect  of  race,  all  cases  in  individuals  over  the 
thirty-ninth  year  of  age  were  in  whites  and  in  every  age-group  below  this 
period  of  life,  with  the  exception  of  the  first  year,  the  attack  rate  was  markedly 
higher  in  whites  than  in  negroes.  While,  on  the  whole,  in  the  first  two  decades 
of  life  the  incidence  was  greater  in  males  than  in  females  in  both  races,  the 
reverse  was  true  from  the  third  to  the  seventh  decade,  inclusive.  This  change 
in  order  of  incidence  is  perhaps  due,  in  some  degree  at  least,  to  the  greater 
facilities  falling  to  the  lot  of  women  in  household  life  for  contact  with  cases  of 
the  disease. 

The  effect  of  season  upon  the  incidence  and  mortality  of  diphtheria  is  very 
distinct.  From  the  curve  of  the  monthly  annual  mortality-rates  (table  70)  it  is 
clear  that  the  highest  fatality  has  commonly  occurred  in  the  fall  and  early 
winter  and  the  lowest  fatality  almost  always  in  the  warmer  months.  In  typical 
years,  from  its  low  point  in  the  summer,  the  mortality-rate  rises  considerably 
and  often  abruptly  in  September  and  continues  to  ascend  through  the  fall 
months  to  a  peak  in  December  or  January,  from  which  the  decline  is  gradual, 
though  often  irregular,  to  the  low  point  in  midsummer.  Months  of  maximum 
mortality,  between  1856  and  1920,  as  expressed  in  percentages  of  the  total 
number  of  years  (table  72)  were:  December  28,  January  25,  November  22, 
October  15,  February  9,  and  March  2.  Months  of  minimum  mortality  similarly 
expressed  were :  July  38,  August  18,  June  17,  May  14,  April  8,  September  3, 
and  November  2.  The  highest  rates  never  occurred  between  April  and  Septem¬ 
ber,  inclusive,  and  with  the  exception  of  one  year,  the  lowest  incidence  fell 
within  these  months. 

The  relation  between  season  and  the  incidence  of  diphtheria  is  shown  even 
more  accurately  in  the  monthly  annual  morbidity-rates  (table  71)  for  the  24 
years,  1897-1920.  The  curves  of  the  morbidity  and  mortality  rates  for  these 
years  follow  the  same  trend,  the  latter  lagging,  as  is  to  be  expected,  about  a 
month  behind  the  former.  Months  of  maximum  incidence,  as  expressed  in 
percentages  of  occurrence  in  these  24  years  (table  72),  were:  November  38, 
December  33,  January  17,  October  8,  and  February  4.  As  determined  on  the 
same  basis,  months  of  minimum  incidence  were:  July  50,  June  and  August, 


356 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


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359 


each  21,  and  May  8.  September,  March,  and  April  were  never  months  of  either 
maximum  or  minimum  incidence. 

Owing  to  the  incompleteness  of  case  reporting,  it  is  manifestly  impracticable 
to  calculate  with  any  accuracy  a  normal  diphtheria  case-fatality  rate  for  Balti¬ 
more  during  the  preantitoxin  days.  In  1895  and  1896  antitoxin  was  used  to 
some  extent;  but  if,  for  the  sake  of  establishing  a  standard  somewhat  arbitrary, 
1896  be  taken  as  a  representative  year,  and  the  favorable  influence  of  the  anti¬ 
toxin  used  on  those  able  to  pay  for  it  and  willing  to  waive  prejudice  against 
the  new  remedy  be  considered  as  offsetting  the  defectiveness  of  case  reporting, 
the  normal  diphtheria  case-fatality  rate  without  antitoxin  treatment  would  be 
42.9  per  cent.  The  much  lower  case-fatality  rate  in  1897  (22.2  per  cent)  when 
antitoxin  was  first  freely  distributed  and  therefore  fairly  widely  used,  may  then 


Table  72. — Maximum  and  minimum  incidence  of  mortality  and  morbidity  from  diph¬ 
theria  by  months,  from  1856  to  1920,  inclusive,  and  from  1897  to  1920,  inclusive,  re¬ 
spectively,  and  the  percentage  of  each  to  the  total  number  of  years. 


Months. 

Months  in  65  years  in 
which  maximum 
mortality-rate 
obtains. 

Months  in  65  years  in 
which  minimum 
mortality-rate 
obtains. 

Months  in  24  years  in 
which  maximum 
morbidity-rate 
obtains. 

Months  in  24  years  in 
which  minimum 
morbidity-rate 
obtains. 

No. 

Percentage  to 
total  years. 

No. 

Percentage  to 
total  years. 

No. 

Percentage  to 
total  years. 

No. 

Percentage  to 
total  years. 

Jan . 

16 

25 

•  •  • 

•  •  • 

4 

17 

•  •  • 

•  •  • 

Feb . 

6 

9 

•  •  • 

•  •  • 

1 

4 

•  •  • 

•  •  • 

Mar . 

1 

2 

•  •  • 

•  •  • 

•  •  • 

•  •  • 

Apr . 

5 

8 

•  ♦  • 

•  •  • 

May  . 

9 

14 

2 

8 

June  . 

11 

17 

5 

21 

July  . 

25 

38 

12 

50 

Aug . 

12 

18 

5 

21 

Sept . 

2 

3 

•  •  • 

•  •  • 

Oct . 

10 

15 

•  •  • 

•  •  • 

2 

8 

•  •  • 

•  •  • 

Nov . 

14 

22 

1 

2 

9 

38 

•  •  • 

•  •  • 

Dec . 

18 

28 

•  •  • 

•  •  • 

8 

33 

•  •  • 

•  •  • 

Total  . . 

65 

100 

65 

100 

24 

100 

24 

100 

be  taken  as  an  index,  admittedly  only  approximate,  of  the  curative  value  of 
antitoxin  as  then  used  and  of  its  immediate  actual  influence  upon  mortality  in 
this  disease.  In  this  year,  as  compared  with  1896,  while  the  morbidity-rate 
increased  by  140  per  cent,  the  mortality-rate  increased  by  only  25  per  cent,  and 
the  case-fatality  rate  fell  by  48  per  cent.  The  case-fatality  rate  fell  by  very 
gradual  steps  in  the  face  of  continually  improved  case  reporting  during  the 
next  7  years  and  reached  the  low  point  of  9  per  cent  in  1904.  The  lowest  point 
attained  was  6.2  per  cent  in  1913.  During  the  first  4  years  during  which  anti¬ 
toxin  was  freely  used,  1897-1900,  the  average  case-fatality  rate  was  18.5  per 
cent,  and  the  average  rates  for  5-year  periods  from  1901  to  1920  were  11.7,  8.9, 
7.1  and  8.6  per  cent.  It  will  be  noted  that  unless  it  be  assumed,  and  for  this 
there  is  no  warrant,  that  case  reporting  has  become  much  more  accurate  in 
the  last  5  years,  the  treatment  of  diphtheria  and  the  management  of  diphtheria 
cases  in  Baltimore  reached  its  high  point  of  efficiency  by  1915,  and  during  the 
last  quinquennium  ground  has  actually  been  lost.  It  is  of  interest  that,  while 


360  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

the  trend  of  the  curve  of  the  case-fatality  rate  follows  very  closely  those  of  both 
morbidity  and  mortality  until  1909,  since  this  date  the  agreement  in  trend  has 
been  almost  completely  lost  so  far  as  concerns  morbidity  and  very  much  modi¬ 
fied  as  concerns  mortality. 

In  recent  years,  the  mortality  from  nasal  and  faucial  diphtheria,  uncompli¬ 
cated  by  laryngeal  involvement,  has  been  comparatively  small.  Of  the  total 
number  of  248  deaths  ascribed  to  diphtheria  in  1919  and  1920,  Dr.  John  F. 
Hogan  found  on  personal  inquiry  of  the  attending  physicians  that  203,  or  82 
per  cent,  had  laryngeal  diphtheria,  and  that  in  45  or  18  per  cent  the  disease 
did  not  involve  the  larynx.  For  the  two  years  the  average  mortality-rates  were 
20  and  14,  respectively. 

Of  the  3,184  deaths  credited  according  to  the  loose  classification  of  those 
times  to  croup  and  to  diphtheria  together  in  the  10-year  period  1863-1872, 
2,258  or  70  per  cent  were  apportioned  to  the  former  and  952  or  30  per  cent  to 
the  latter.  If  it  be  justifiable  to  assume  that  in  this  series  deaths  assigned  to 
croup  represented  laryngeal  diphtheria  and  those  ascribed  to  diphtheria  repre¬ 
sented  faucial  and  nasal  diphtheria  without  laryngeal  involvement,  it  would 
appear  that  antitoxin  treatment  has  exercised  a  less  striking  influence  upon  the 
relative  fatality  of  these  two  anatomical  forms  of  diphtheria  than  is  commonly 
supposed.  Unfortunately,  for  neither  of  these  groups  are  data  available  as  to 
the  relative  morbidity  of  laryngeal  and  faucial  diphtheria. 

The  influence  of  sex  and  color  also  upon  mortality  was  signifiant  for  the  15- 
3*ear  period,  1906-1920,  for  which  specific  data  are  available.  The  1,221  deaths 
during  this  period  were  distributed  by  sex  and  color  as  follows :  White  1,129, 
negro  92,  white  males,  576,  white  females  553,  negro  males  47,  negro  females  45. 
The  deaths  among  whites  and  negroes  were  in  the  ratio  of  12  to  1,  while  the 
proportion  of  whites  to  negroes  in  the  population  was  on  the  average  5.42  to  1 ; 
i.  e.,  diphtheria  was  more  than  twice  as  fatal  for  whites  as  for  negroes.  In  both 
races  the  fatality  was  distinctly  higher  in  males  than  in  females.  This  is  greatly 
at  variance  with  the  experience  for  1850,  when,  according  to  Frick,  the  mortality 
per  10,000  from  croup  was  8.5  in  whites  and  8.8  in  negroes,  and  of  the  whole 
number  of  deaths  for  both  races  49  per  cent  were  in  males  and  51  per  cent 
in  females. 

In  tables  62  and  63  death-rates  by  age,  color,  and  sex  are  given  for  the 
census  years  1910  and  1920.  No  deaths  occurred  in  individuals  over  the  fortieth 
year,  nearly  the  whole  mortality  fell  within  age-period  0  to  9  years,  and  over 
three-fourths  of  it  below  the  fifth  year  of  life.  Of  the  142  deaths  from  croup  in 
1850  analyzed  by  Frick  (table  73),  134,  or  94  per  cent,  were  under  5  years  of 
age.  In  both  1910  and  1920  the  rates  were  much  higher  in  whites  than  in 
negroes.  In  1910  mortality  was  greater  in  males  than  in  females  in  both  races, 
and  in  1920  in  females  than  in  males  among  whites  and  in  males  than  in  females 
among  negroes. 

Up  to  about  1900  the  whole  course  of  diphtheria  in  Baltimore  may  be  regarded 
as  natural  and  practically  uninfluenced  by  artificial  interferences,  for  certainly 
before  1898  no  measures  of  a  restrictive  kind,  which  may  by  any  stretch  of 
the  imagination  be  considered  effective,  were  directed  against  the  disease  by  the 
health  department.  And  no  one  who  has  read  the  text-book  directions  or  sug¬ 
gestions  for  the  treatment  of  diphtheria  or  who  has  seen  them  applied  will  con¬ 
tend  that,  before  the  general  use  of  the  O’Dyer  intubation  method  and  of  anti- 


FEBRILE  DISEASES 


361 


toxin  during  the  late  years  of  the  nineteenth  century,  physicians,  on  the  whole, 
saved  more  diphtheria  patients  than  they  killed.  What  influence  immigration 
exerted  upon  the  course  of  diphtheria  in  Baltimore  it  is  impossible  to  say. 
The  coincidence  of  the  rise  in  the  second  wave  with  the  large  foreign  migration 
starting  in  the  fifth  decade  of  the  nineteenth  century  and  of  its  fall  with  decrease 
in  migration  in  its  latter  years  may  be  significant.  At  any  rate,  it  is  not  unlikely 
that  the  decline  in  the  death-rate  between  1820  and  1830  represented  a  true 
decrease  in  virulence  of  the  type  of  diphtheria  then  locally  prevalent,  and  that 
the  second  wave  was  associated,  in  part  at  least,  with  importation  of  the  disease 
in  more  potent  form  from  Europe  during  the  exacerbation  of  the  disease  about 
the  middle  of  the  century.  It  is  of  considerable  interest,  in  connection  with 
the  second  wave,  that  during  the  35  years,  1840-1875,  marking  its  first  phase, 
the  average  annual  death-rate  from  diphtheria  was  100,  and  during  the  25  years 
of  its  second  phase,  1875-1900,  it  was  107. 


Table  73. — Number  of  deaths  and  rate  of  death,  per  100,000 
living  inhabitants,  from  croup,  according  to  age,  for  1850. 
Calculated  from  figures  given  in  Frick’s  tables. 


Age-period. 

Croup. 

Deaths. 

Rate. 

Under  1  year . . 

54 

881 

I  to  4  years . 

80 

434 

5  to  9  years . 

8 

40 

Under  10  years . 

142 

318 

10  to  19  years . 

20  to  29  years . 

30  to  39  years . 

40  to  49  years . 

50  to  59  years . 

60  years  and  over . 

Total  . 

142 

84 

For  this  period  there  exist  no  data  for  morbidity-rates.  Viewed  from  the 
annual  mortality-rates,  the  curve  of  diphtheria  mortality  reached  its  highest 
point  in  1882.  From  this  date  the  fall  in  the  death-rate  was  continuous  to  1908, 
except  for  comparatively  minor  rises  covering  the  years  1890-1892  and  1894- 
1900.  These  minor  waves,  to  which  attention  has  already  been  directed,  did  not 
approach,  however,  the  immediately  previous  high  level.  It  is  to  be  noted  that 
the  highest  point  of  this  second  minor  wave,  considerably  lower  than  that  of 
the  one  of  1890-1892,  was  in  1899.  These  two  breaks  in  the  curve  of  descent  in 
the  diphtheria  mortality-rate  may  be  regarded  as  reactions  from  a  rather  sudden 
fall  and  as  an  indication  of  a  tendency  of  the  disease  to  reach  an  equilibrium 
and  a  death-rate  of  between  60  and  70.  On  the  other  hand,  as  the  artificial 
interferences,  begun  in  1897  and  1898,  which  will  be  more  fully  explained 
later,  could  not  have  offered  any  decided  and  compelling  resistance  until  several 
years  later,  it  is  not  unlikely  that  under  natural  conditions  a  much  lower  rate 
than  49  reached  in  1889  might  have  been  attained  and  the  point  of  equilibrium 
established  for  a  period  at  least  around  a  rate  of  40  or  even  lower,  as  obtained 
for  the  20  years  between  1826  and  1845. 


362  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

It  is  interesting  to  note  that  in  1883  a  high  rate  was  recorded  for  scarlet 
fever,  and  that  the  rates  for  these  two  diseases  fell  simultaneously,  though  the 
descent  in  diphtheria  was  much  less  rapid  and  striking  than  in  scarlet  fever. 

The  development  and  application  of  restrictive  measures  against  the  spread 
of  diphtheria  were  very  gradual.  As  previously  pointed  out,  though  mem¬ 
branous  croup  was  made  reportable  in  1882  and  diphtheria  in  1894,  reports 
were  not  made  at  all  until  1893,  and  not  with  any  completeness  until  1898 
or  1900. 

Though  the  bacteriological  laboratory  was  available  for  diagnosis,  and  anti¬ 
toxin  was  obtainable  for  protection  and  treatment  in  1896  and  1897,  it  was 
some  years  before  they  were  very  generally  used.  It  was  not  until  1898  that 
warning  signs  were  posted  on  dwellings  and  institutions  harboring  diphtheria 
cases,  that  isolation  of  diphtheria  patients  was  seriously  attempted,  that  a  nega¬ 
tive  throat-culture  (taken  by  the  attending  physician  or  by  the  single  throat 
inspector  appointed  this  year)  was  required  from  the  patient  and  household  con¬ 
tacts  before  disinfection  and  release,  and  that  children  were  not  allowed  to 
return  to  public  schools  without  a  certificate  of  recovery.  During  this  same  year 
there  was  instituted  semi -weekly  notification  to  each  public  school  of  the  names 
and  addresses  of  any  pupils  sick  with  diphtheria  and  scarlet  fever.  In  1900  a 
second  throat  inspector  was  appointed  to  make  cultures  for  release  of  diphtheria 
convalescents. 

Precautions  against  spread  of  the  disease  through  contacts  and  carriers,  by 
means  of  milk  and  other  foods,  and  the  control  of  milk  and  cream  from  farms 
and  dairies  exposed  to  known  cases  and  contacts  were  not  routinely  undertaken, 
with  any  completeness  at  least,  until  after  1912.  As  late  as  1910,  in  only  395 
of  the  793  cases  of  diphtheria  reported  was  the  diagnosis  confirmed  by  culture, 
and  of  the  3,401  cultures  for  discharge  taken  by  the  throat  inspectors  and 
private  physicians  from  convalescents  and  from  contacts,  only  289  were  positive. 
The  next  year  the  throat  inspectors  began  taking  nasal  as  well  as  faucial 
cultures,  but  only  one  negative  culture  from  each  situation  was  required,  and 
if  either  throat  or  nose  culture  were  found  negative  on  one  occasion  it  was 
counted  as  permanently  negative  and  future  cultures  were  confined  to  the  organ 
found  positive.  When  diphtheria  broke  out  in  institutions,  cultures  were  made 
from  all  the  inmates,  the  carriers  were  isolated  in  a  group,  and  those  who  were 
found  negative  on  a  single  culture-test  were  discharged.  In  St.  Vincent’s 
Orphan  Asylum,  with  its  large  population  of  sucklings  and  older  children,  in 
connection  with  these  imperfect  measures  and  the  total  lack  of  rooms  for  iso¬ 
lation  of  incoming  as  well  as  permanent  inmates,  diphtheria  continued  endemic. 

In  December  1915  these  regulations  and  practices  were  so  amplified  that  two 
consecutive  negative  cultures  taken  at  intervals  of  at  least  48  hours  from 
both  nose  and  throat  were  required  before  release  of  convalescents  and  contacts ; 
all  contacts  and  reported  cases  were  submitted  to  culture;  all  carriers  and  all 
attendants,  whether  proven  carriers  or  not,  were  isolated ;  and  other  members 
of  households  with  diphtheria  cases  after  two  negative  nose  and  throat  cultures 
were  allowed  to  mix  with  the  public  at  will,  if  the  isolation  of  the  patient  and 
any  carriers  in  the  households  was  complete,  or  on  change  of  domicile.  In  the 
case  of  both  convalescents  and  healthy  carriers,  virulence  tests  were  made  after 
the  twenty-eighth  day,  and  if  their  cultures  proved  non-virulent  for  guinea- 
pigs  they  were  released.  Within  the  next  2  years  hospitals  and  institutions 


FEBRILE  DISEASES 


3G3 


receiving  children  were  required,  except  in  emergencies,  to  make  cultures  of 
prospective  inmates  before  admission  and  to  establish  suitable  isolation  quarters 
for  diphtheria  cases  and  carriers  or  to  send  them  to  Sydenham  Hospital.  All 
cultures  for  discharge  were  required  to  be  taken  by  representatives  of  the 
health  department.  Members  of  the  classes  of  school-children  developing  diph¬ 
theria  were  cultured  and  those  found  to  be  diphtheria  carriers  excluded. 

These  procedures,  with  strict  supervision  of  the  disinfection  of  all  milk 
utensils  before  returning  to  dairymen,  enormously  increased  the  work  of  the 
health  department  in  connection  with  diphtheria.  The  work  of  the  bacteriologi¬ 
cal  laboratory  was  greatly  augmented — from  an  average  of  80  to  90  diphtheria 
cultures  on  an  average  day  in  the  winter  to  400.  In  1920  there  were  62,644 
cultures  examined,  14,037  from  inmates  of  institutions  and  48,607  from  house¬ 
holds  or  schools;  of  the  latter  number,  3,848  were  submitted  for  diagnosis, 
17,992  were  from  contacts,  and  26,767  were  for  discharge  of  convalescents  or 
contactive  carriers,  an  average  of  over  160  diphtheria  cultures  every  day  in 
the  year. 

In  the  meantime,  since  1910  an  increasing  number,  but  never  any  consider¬ 
able  moiety  of  the  total  number  of  cases  of  diphtheria,  and  some  chronic 
carriers,  were  treated  at  Sydenham  Hospital.  This  hospital,  though  incon¬ 
veniently  situated,  faulty  in  design,  and  inadequately  equipped,  managed  diph¬ 
theria  cases  in  a  manner  wholly  creditable  until  the  depletion  of  its  personnel 
during  the  war,  and,  while  it  can  not  have  exerted  any  considerable  influence 
upon  restricting  morbidity,  it  has  undeniably  been  responsible  for  influencing 
favorably  the  mortality  from  this  disease.  Its  chief  service  in  this  regard  has 
been  rendered  in  the  intelligent  care  of  cases  of  laryngeal  diphtheria,  many  of 
which,  however,  have  reached  it  too  late  to  be  saved  by  intubation,  antitoxin, 
and  nursing.  Its  clientele  in  this  group  of  cases  has  been  drawn  largely  from 
the  poor  and  ignorant  and  often  referred  when  in  articulo  mortis  by  physicians 
called  after  the  disease  was  far  advanced. 

ACUTE  INFLAMMATORY  AFFECTIONS  OF  THE  LUNGS  AND  PLEURA;  I.  E., 

BRONCHITIS,  PNEUMONIA,  AND  PLEURISY. 

The  affections  here  considered  are  grouped  upon  a  purely  anatomical  basis, 
and  the  only  member  of  the  group,  croupous  or  lobar  pneumonia,  for  which  the 
evidence  at  hand  indicates  the  action  of  a  specific  cause,  is,  certainly  during 
most  and  probably  during  all  of  the  period  for  which  records  exist,  so  hopelessly 
intermixed  and  confused  in  the  nosological  classification  that  it  is  not  possible 
to  separate  it  out  with  any  reasonable  degree  of  accuracy.  Pleurisy  is  so  evi¬ 
dently  bound  up  with  pneumonia  that  even  in  later  years  it  can  not  certainly 
be  set  up  as  a  separate  category.  Deaths  listed  under  bronchitis  undoubtedly 
included  many  due  to  pneumonia,  and  only  recently  was  there  a  distinction 
made  between  acute  and  chronic  bronchitis.  In  table  60,  the  categories  to  which 
deaths  under  these  various  groupings  were  assigned  are  arranged  in  chronologi¬ 
cal  order.  It  will  be  noted  that  pleurisy  alone  appeared  before  1818,  played  the 
leading  role  until  1822,  and  continued  to  be  a  serious  rival  of  the  other  cate¬ 
gories  for  many  years  later.  Inflammation  of  the  lungs  made  its  appearance 
with  credit  for  a  relatively  considerable  number  of  deaths  in  1818,  then  in  a 
few  years  receded  to  an  inconspicuous  position,  and  did  not  become  important 
24 


364  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

again  until  about  1850.  It  almost  entirely  disappeared  after  1874.  Pneumonia 
first  appeared  in  the  nosological  classification  in  1821,  with  a  few  deaths  for 
2  years;  in  1823  it  rivaled  pleurisy  and  surpassed  inflammation  of  the  lungs 
and  then  practically  disappeared,  except  for  the  6  years  between  1845  and  1850, 
until  1875,  when  it  became  the  one  prominent  cause  of  death  in  this  whole 
group.  In  the  meantime,  catarrhal  fever,  which  in  1855  Frick  held  to  be  infan¬ 
tile  pneumonia  and  bronchitis,  appeared  in  1823,  and  soon  began  to  equal  and 
then  to  surpass  in  numbers,  first,  any  other,  and  then,  about  1840,  all  other  cate¬ 
gories  of  this  group.  As  late  as  1898  a  few  deaths  were  ascribed  to  catarrhal 
fever.  Broncho-pneumonia  appeared  in  the  nosology  in  1879  with  4  deaths. 
The  proportion  of  deaths  classified  under  this  heading  increased  very  gradually, 
and  finally  by  1920  nearly  half  of  the  total  number  of  deaths  credited  to  pneu¬ 
monia  were  classed  under  this  heading. 

Bronchitis  appeared  as  a  separate  disease  in  1841  (with  5  deaths),  but  was 
not  ascribed  any  considerable  number  of  deaths  (46)  until  1872.  It  lapsed 
completely  in  1875  and  appeared  only  once  again,  in  1898.  It  was  supplanted 
by  inflammation  of  the  bronchi,  to  which  an  increasingly  large  number  of 
deaths  was  credited  until  it  in  turn  sank  into  oblivion  in  1898.  Capillary  bron¬ 
chitis  appeared  as  a  cause  of  death  from  1878  until  1900.  The  terms  “  acute  ” 
and  “  chronic 99  bronchitis,  introduced  with  the  adoption  of  the  international 
classification  in  1899,  have  shared  with  each  other  all  the  deaths  credited  to 
bronchitis  since  that  date. 

From  this  rapid  review  it  is  clear  that  by  no  method  of  arrangement  can  the 
figures  under  these  various  categories  be  so  grouped  as  to  indicate  with  any 
reasonable  degree  of  definitiveness  the  true  proportion  of  deaths  ascribable  to 
acute  or  chronic  bronchitis,  or  to  broncho  and  lobar  pneumonia,  or  to  primary 
pleurisy.  In  the  early  days  pleurisy  must  have  included  not  only  all  forms  of 
acute  pneumonia,  but  some  deaths  from  phthisis,  chronic  cardiac  disease,  and 
the  like.  Pneumonia,  catarrhal  fever,  and  inflammation  of  the  lungs  must  have 
included  some  deaths  of  persons  with  bronchitis,  acute  and  chronic,  as  well  as 
deaths  of  individuals  with  various  other  acute  and  chronic  diseases  that  would 
now  be  otherwise  classified.  Catarrhal  fever  and  capillary  bronchitis,  synonyms 
for  catarrhal  pneumonia,  properly  belonged  and,  since  1900,  have  fallen 
to  broncho-pneumonia.  It  is  probable  that  in  most  if  not  all  the  fatalities 
ascribed  to  acute  bronchitis  the  inflammatory  process  also  involves  the  lung, 
and  that  this  term  as  used  signifies  pneumonia,  usually  broncho-pneumonia. 
Particularly  in  the  light  of  the  experience  of  MacCallum  and  of  other  pathologi¬ 
cal  anatomists,  studying  the  abundant  army  material  in  the  late  war,  it  is 
very  improbable  that  much  dependence  can  be  placed  upon  the  diagnosis  of 
broncho-pneumonia  as  distinguished  from  lobar  pneumonia,  in  at  least  a  very 
large  proportion  of  instances  as  certified  upon  death  certificates  without  post¬ 
mortem  examination.  Chronic  bronchitis,  to  which  some  deaths  continue  to 
be  ascribed  to  the  end  of  the  period,  can  not  be  separated  from  acute  bronchitis 
before  1899,  and  is  therefore  included  with  acute  bronchitis  to  avoid  an  incon¬ 
sistency  even  greater  were  it  omitted. 

From  these  observations  and  explanations  it  would  appear  that  rates  calcu¬ 
lated  for  any  single  one  of  the  above  categories  would  be  without  value;  that 
rates  calculated  on  the  basis  of  the  sums  of  the  categories  as  arranged  under 
bronchitis,  or  under  pneumonia  and  pleurisy,  can  have  no  definitely  significant 


FEBRILE  DISEASES 


365 


value;  and  that  rates  calculated  on  the  basis  of  the  sum  of  the  deaths  under  all 
the  categories  relating  to  bronchitis,  pneumonia,  and  pleurisy  are  relatively 
significant,  but  subject,  of  course,  to  uncertain  errors  due  to  idiosyncrasies  of 
classification,  to  errors  of  diagnosis,  and  to  the  custom  only  in  recent  years 
successfully  overcome  of  ascribing  to  bronchitis  and  pneumonia  deaths  of 
individuals  with  various  acute  and  chronic  diseases  in  which  pulmonary  com¬ 
plications  are  secondary. 

Despite  the  numerous  faults  of  classification  above  pointed  out,  it  is  evident 
from  table  60,  graph  17  (in  which  are  given  separately  rates  calculated  for 
bronchitis,  pneumonia,  and  the  total  of  the  two),  that  the  acute  pulmonic 
diseases  were  well  established  as  important  causes  of  death  early  in  the  nine¬ 
teenth  century.  Taken  together,  they  started  with  a  death-rate  of  139  in  1812 
and  in  1814  attained  a  rate  (246)  not  surpassed  until  1890-1896,  and  in  9 
other  years  subsequent  to  the  latter  date.  It  was  not  until  1874  that  bronchitis, 
introduced  into  the  statistical  nosology  in  1841,  began  to  rank  significantly;  and 
since  1904  its  importance  has  gradually  declined  until  by  1919  it  had  again 
become  an  insignificant  factor.  It  will  be  noted  that,  while  coincident  with  the 
rise  here  in  the  curve  for  bronchitis  and  a  slight  corresponding  fall  in  the  curve 
for  pneumonia,  the  curve  for  the  combined  rate  is  not  dependent  upon  the 
introduction  of  a  new  factor.  On  the  whole,  it  seems  improbable  that  the  differ¬ 
entiation  of  bronchitis  into  separate  statistical  rubrics  really  increased  in  any 
considerable  degree  the  number  of  deaths  that  otherwise  would  have  been 
credited  to  acute  pulmonic  disease  and  thereby  actually  increased  the  rate. 

In  the  course  of  the  curve  of  the  rate  for  the  combined  group  of  acute  pul¬ 
monic  diseases  there  are  several  noticeable  waves.  The  first  wave,  covering  a 
period  of  20  years,  began  in  1812,  reached  its  high  point  in  1814,  with  a  rate 
of  246,  and  gradually  subsided,  after  considerable  fluctuations  toward  the  end 
of  the  period,  to  a  rate  of  70  in  1831.  The  second  wave,  1832—1840,  reached  its 
high  point  of  160  in  1835  and  its  low  point  of  83  in  1840.  The  third  wave, 
1841-1865,  was  marked  by  several  minor  waves.  The  highest  rates  attained 
were  170  in  1848  and  206  in  1852.  A  fourth  wave  reached  a  peak  in  1872  with 
a  rate  of  222  and  gradually  descended  to  150  in  1878.  The  next  year  the  rate 
rose  and  maintained  a  rather  constant  level  of  about  200  until  1889.  In  this 
and  the  next  year  rates  of  308  and  315  were  reached  and  between  1892  and  1899 
the  annual  rates  varied  between  224  and  290.  After  a  rise  to  317  in  1900,  the 
rate  fell  to  203  in  1908.  With  minor  fluctuations,  the  annual  rate  hovered 
around  225  until  1915 ;  it  began  to  rise  in  1916,  and,  in  the  influenza  year  1918, 
reached  607.  During  the  next  2  years  it  fell  to  about  200.  It  will  be  noted  that 
since  about  1830  the  rate  for  the  acute  pulmonic  diseases  has  been  rising. 

The  curve  of  the  rates  averaged  for  5-year  periods  (table  61,  graph  18)  fell 
abruptly  from  a  high  point  in  1812-1815  to  75  in  1821-1825;  from  this  it 
ascended  by  gradual  steps  to  a  rate  of  165  reached  in  1851-1855.  A  drop 
during  the  next  10  years  to  97  wras  followed  by  another  gradual  ascent  to  an 
average  rate  of  277  in  1891-1895.  Following  a  graduated  decline,  a  rate  of  222 
was  reached  in  1911-1915,  and  from  this  there  was  a  jump  to  305  in  1916-1920. 

With  the  annual  mortality  rates  averaged  for  10-year  periods  (table  61, 
graph  19),  from  a  peak  of  159  in  1812-1820,  the  rates  fell  abruptly  to  77  in 
1821-1830.  The  peak  of  a  second  "wave  was  attained  in  1851-1860,  with  a  rate 


366 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


of  149.  After  a  moderate  drop  to  122  in  1861-1870,  the  rate  rose  steadily  to  272 
in  1891-1900.  Following  a  slight  recession  to  243  in  1901-1910,  the  rate  rose 
to  264  in  1911-1920. 

A  straight  line  fitted  to  the  curve  of  rates  averaged  by  5-  and  10-year  periods, 
from  1825  to  1920,  would  follow  a  progressively  increasing  death-rate  from  the 
pulmonic  diseases  during  a  period  covering  95  years.  The  full  significance  of 
this  fact  and  of  the  fall  culminating  in  1825  will  be  discussed  in  another 
section. 

The  absolute  figures  for  deaths  and  the  death-rates  for  broncho  and  lobar 
pneumonia  from  1906  to  1920,  and  for  bronchitis  from  1905  to  1915,  both  for 
sex  and  color,  are  set  forth  in  table  74.  The  lessons  to  be  drawn  from  the  curves 

Table  74. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from 
pneumonia  and  bronchitis,  according  to  color  and  sex,  from  1905  to  1920,  inclusive  * 

D  =  death.  It  =  rate. 


TOTAL  PNEUMONIA. 


Year. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1905  . 

1906  . 

650 

141 

329 

146 

321 

136 

372 

438 

206 

539 

166 

351 

1907  . 

685 

147 

376 

165 

309 

129 

409 

475 

224 

577 

185 

391 

1908  . 

583 

123 

293 

127 

290 

120 

357 

409 

185 

469 

172 

359 

1909  . 

723 

151 

366 

157 

357 

146 

392 

443 

204 

510 

188 

388 

1910  . 

770 

160 

395 

167 

375 

152 

289 

322 

160 

394 

129 

263 

1911  . 

733 

150 

378 

158 

355 

143 

381 

419 

211 

512 

170 

342 

1912  . 

687 

140 

349 

144 

338 

135 

361 

392 

199 

476 

162 

322 

1913  . 

797 

160 

417 

171 

380 

151 

401 

430 

212 

500 

189 

372 

1914  . 

834 

166 

442 

179 

392 

154 

367 

389 

204 

475 

163 

317 

1915  . 

768 

152 

399 

160 

369 

144 

364 

381 

200 

459 

164 

315 

1916  . 

947 

186 

503 

200 

444 

172 

455 

470 

242 

548 

213 

405 

1917  . 

907 

176 

521 

205 

386 

148 

554 

566 

322 

720 

232 

437 

1918  . 

2697 

520 

1538 

599 

1159 

443 

830 

838 

428 

944 

402 

749 

1919  . 

962 

156 

518 

169 

444 

143 

354 

339 

201 

420 

153 

271 

1920  . 

1030 

165 

502 

163 

528 

167 

363 

334 

185 

347 

178 

321 

BRONCHOPNEUMONIA. 


1905  . 

1906  . 

241 

52 

122 

54 

119 

50 

143 

168 

71 

186 

72 

152 

1907  . 

227 

49 

123 

54 

104 

43 

128 

149 

64 

165 

64 

135 

1908  . 

191 

40 

92 

40 

99 

41 

125 

143 

65 

165 

60 

125 

1909  . 

225 

47 

122 

52 

103 

42 

155 

175 

73 

182 

82 

169 

1910  . 

252 

52 

114 

48 

138 

56 

102 

114 

50 

123 

52 

106 

1911  . 

273 

56 

137 

57 

136 

55 

139 

153 

77 

187 

62 

125 

1912  . 

314 

64 

152 

63 

162 

65 

145 

158 

77 

184 

68 

135 

1913  . 

375 

75 

191 

78 

184 

73 

189 

203 

92 

217 

97 

191 

1914  . 

409 

82 

198 

80 

211 

83 

164 

174 

92 

214 

72 

140 

1915  . 

363 

72 

172 

69 

191 

75 

178 

186 

89 

204 

89 

171 

1916  . 

393 

77 

192 

76 

201 

78 

218 

225 

102 

231 

116 

221 

1917  . 

383 

74 

215 

84 

168 

65 

206 

211 

112 

250 

94 

177 

1918  . 

729 

141 

411 

160 

318 

121 

265 

268 

102 

225 

163 

304 

1919  . 

474 

77 

257 

84 

217 

70 

186 

178 

109 

228 

77 

137 

1920  . 

506 

81 

242 

78 

264 

83 

184 

169 

95 

178 

89 

160 

*  The  totals  of  these  figures,  which  were  obtained  from  special  tables  in  the  annual 
reports,  do  not  always  correspond  with  those  of  the  tables  of  deaths  from  all  causes,  but 
their  proportionate  distribution  by  color  and  sex  may  be  regarded  as  relatively  accurate. 


FEBRILE  DISEASES 


367 


Table  74. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from 

pneumonia,  bronchitis,  etc. — Continued. 


LOBAR  PNEUMONIA. 


Year. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1905  . 

1906  . 

409 

88 

207 

92 

202 

85 

229 

270 

135 

353 

94 

199 

1907  . 

458 

98 

253 

111 

205 

86 

281 

326 

160 

412 

121 

256 

1908  . 

392 

83 

201 

87 

191 

79 

232 

266 

120 

304 

112 

234 

1909  . 

498 

104 

244 

104 

254 

104 

237 

268 

131 

327 

106 

219 

1910  . 

518 

107 

281 

119 

237 

96 

187 

209 

110 

271 

77 

157 

1911  . 

460 

94 

241 

101 

219 

88 

242 

266 

134 

325 

108 

217 

1912  . 

373 

76 

197 

81 

176 

70 

216 

235 

122 

292 

94 

187 

1913  . 

422 

85 

226 

92 

196 

78 

212 

227 

120 

283 

92 

181 

1914  . 

425 

85 

244 

99 

181 

71 

203 

215 

112 

261 

91 

177 

1915  . 

405 

80 

227 

91 

178 

69 

186 

195 

111 

255 

75 

144 

1916  . 

554 

109 

311 

123 

243 

94 

237 

245 

140 

317 

97 

185 

1917  . 

524 

102 

306 

120 

218 

84 

348 

356 

210 

469 

138 

260 

1918  . 

1968 

379 

1127 

439 

841 

321 

565 

571 

326 

719 

239 

445 

1919  . 

488 

79 

261 

85 

227 

73 

168 

161 

92 

192 

76 

135 

1920  . . 

524 

84 

260 

84 

264 

83 

179 

165 

90 

169 

89 

160 

BRONCHITIS. 


1905  . 

1906  . 

1907  . 

1908  . 

1909  . 

1910  . 

1911  . 

1912  . 

1913  . 

1914  . 

1915  . 

1916  . 

156 

133 

134 

115 
104 
125 
108 
112 

116 
112 

96 

34 

29 

29 

24 

22 

26 

22 

23 

23 

22 

19 

75 

71 

63 

54 

37 

56 

46 

47 
58 
54 
42 

34 

31 

28 

23 
16 

24 
19 
19 
24 
22 
17 

81 

62 

71 

61 

67 

69 

62 

65 

58 

58 

54 

35 

26 

30 

25 

27 

28 

25 

26 
23 
23 
21 

90 

74 

48 

48 

37 

32 

44 

36 

51 

40 

30 

108 

87 

56 

55 

42 

36 

48 

39 

55 

42 

31 

43 

38 

19 

24 

17 
13 

18 
18 

27 

28 
9 

114 

99 

49 

61 

42 
32 
44 

43 

64 

65 
21 

47 

36 

29 

24 

20 

19 

26 

18 

24 

12 

21 

102 

76 

61 

50 

41 

39 
52 
36 
47 
23 

40 

1917  . 

1918  . 

1919  . 

1920  . 

of  these  rates  are  so  clear  that  extended  discussion  is  unnecessary.  The  wide 
difference  in  the  rates  for  pneumonia  (broncho  and  lobar  combined)  in  whites 
and  in  negroes  is  striking.  The  general  trend  of  the  curves  of  these  rates  follow 
each  other  closely;  a  marked  difference  occurs  in  only  one  year,  1910,  when 
there  is  a  decided  dip  in  the  rate  for  colored,  without  a  corresponding  change 
in  the  rate  for  white.  The  increase  in  the  rate  in  the  influenza  year,  1918,  is 
notably  greater  in  whites  than  in  colored. 

Similarly,  the  course  of  the  curves  for  pneumonia  in  male  and  female  white 
and  colored  shows  a  remarkably  close  correspondence,  a  feature  lacking  in  the 
curves  for  bronchitis.  The  decidedly  lower  death-rates  for  pneumonia  in  females 
in  both  races  is  evident. 


368  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


When  the  annual  rates  for  each  of  these  categories  is  averaged  for  pneumonia 
for  the  period  1906-1920,  and  for  bronchitis  for  the  period  1905-1915,  the  rates 
for  white  and  colored  stand  in  the  following  ratios  to  each  other :  Total  pneu¬ 
monia  as  1:  2.47  (179  to  443)  ;  broncho-pneumonia  as  1:  2.57  (69  to  178)  ; 
lobar  pneumonia  as  1:2.40  (110  to  265);  and  bronchitis  as  1:2.19.  Thus, 
under  each  category  the  death-rate  is  greater  by  two  and  a  quarter  to  two  and 
a  half  times  in  colored  than  in  white. 

The  averaged  rates  for  the  same  categories  for  sex  and  color  show  ratios  as 
follows :  Total  pneumonia,  males  to  females,  white  1.17  :  1  (194  to  166),  colored 
1.41:1  (526  to  374);  broncho-pneumonia,  males  to  females,  white  1.08:1 
(72  to  67),  colored  1.20: 1  (196  to  163) ;  lobar  pneumonia,  males  to  females, 
white  1.23  :  1  (122  to  99),  colored,  1.57 : 1  (330  to  210) ;  and  bronchitis,  males 
to  females,  white  1:  1.13  (22  to  26),  colored,  1.12:  1  (58  to  52).  Therefore, 
pneumonia,  both  broncho  and  lobar,  is  considerably  more  fatal  for  males  than 
for  females  of  both  races,  and  bronchitis  is  somewhat  more  fatal  for  white 
females  and  for  colored  males.  In  like  manner,  when  the  totals  for  the  absolute 
figures  for  the  deaths  of  whites  and  negroes  during  these  periods  are  compared, 
the  ratios  are  heavily  against  the  negro;  total  pneumonia,  1.96:  1,  broncho¬ 
pneumonia,  2.12:1,  lobar  pneumonia,  2.26:1,  and  bronchitis,  2.47:1,  while 
the  proportion  of  negroes  to  whites  in  the  population  during  this  period  was 
as  1 :  5.42. 

Death-rates,  specific  in  regard  to  age  for  sex  and  color  for  the  census  year 
1910,  for  bronchitis,  broncho-pneumonia,  lobar  pneumonia,  and  total  pneu¬ 
monia,  are  shown  in  table  75.  Owing  to  certain  small  discrepancies  in  the 
official  tables  and  to  the  forced  omission  of  pleural  affections,  the  absolute 
figures  and  the  rates  under  the  different  categories  are  not  in  exact  agreement 
with  those  presented  in  previous  tables.  It  is  evident  from  inspection  of  the 


Table  75. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from 
bronchitis  and  pneumonia,  according  to  age,  for  1910. 


D  =  death.  R  =  rate. 
TOTAL  PNEUMONIA. 


Age  period. 

Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

Under  1  year . 

231 

2256 

154 

1732 

77 

1715 

77 

1749 

77 

5712 

44 

6423 

33 

4962 

Betw.  1  and  2  years 

101 

1051 

78 

919 

42 

958 

36 

878 

23 

2041 

10 

1795 

13 

2281 

2  to  4  years . 

94 

293 

59 

211 

29 

206 

30 

216 

35 

842 

23 

1143 

12 

560 

5  to  9  years . 

22 

44 

17 

39 

8 

37 

9 

42 

5 

78 

1 

33 

4 

119 

Under  10  years.... 

448 

441 

308 

348 

156 

350 

152 

346 

140 

1073 

78 

1235 

62 

921 

10  to  19  years . 

27 

26 

17 

19 

11 

26 

6 

13 

10 

73 

5 

85 

5 

63 

20  to  29  years . 

52 

46 

25 

27 

23 

52 

2 

4 

27 

131 

15 

166 

12 

104 

30  to  39  years . 

83 

93 

53 

72 

24 

67 

29 

77 

30 

190 

20 

261 

10 

123 

40  to  49  years . 

66 

96 

41 

72 

24 

87 

17 

57 

25 

219 

14 

248 

11 

192 

50  to  59  years . 

99 

219 

79 

202 

45 

238 

34 

169 

20 

330 

12 

405 

8 

258 

60  to  69  years . 

114 

460 

93 

424 

57 

577 

36 

299 

21 

727 

11 

833 

10 

638 

70  to  79  years . 

113 

1081 

105 

1110 

38 

965 

67 

1214 

8 

803 

2 

496 

6 

1012 

80  years  and  over . . 

57 

2134 

49 

2063 

17 

1981 

32 

2109 

8 

2703 

3 

3226 

5 

2463 

Total  . 

1059 

190 

770 

163 

395 

173 

,375 

153 

289 

340 

160 

406 

129 

282 

FEBRILE  DISEASES 


369 


Table  75. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from 
bronchitis  and  pneumonia,  according  to  age,  for  1910. — Continued. 


BRONCHOPNEUMONIA. 


Ta+  n  1 

White. 

Colored. 

1  Old** 

Age  period. 

Total. 

Male. 

Fern. 

Total. 

Male. 

Fein. 

D 

R 

D 

R 

n 

it 

D 

It 

D 

R 

D 

R 

D 

R 

Under  1  year . 

140 

1367 

95 

1069 

45 

1002 

50 

1136 

45 

3338 

22 

3212 

23 

3459 

Betw.  1  and  2  years 

54 

562 

43 

507 

27 

616 

16 

390 

11 

976 

5 

898 

6 

1053 

2  to  4  years . 

46 

143 

27 

97 

12 

85 

15 

108 

19 

457 

11 

547 

8 

373 

5  to  9  years . 

10 

20 

8 

19 

4 

18 

4 

19 

2 

31 

•  •  • 

•  •  •  • 

2 

60 

Under  10  years.... 

250 

246 

173 

195 

88 

197 

85 

193 

77 

590 

38 

602 

39 

379 

10  to  19  years . 

3 

3 

1 

1 

1 

2 

•  •  • 

•  •  •  • 

2 

15 

•  .  . 

.  .  .  . 

2 

25 

20  to  29  years . 

5 

4 

1 

1 

•  •  • 

•  •  •  • 

1 

2 

4 

19 

2 

22 

2 

17 

30  to  39  years . 

5 

6 

4 

5 

2 

6 

2 

5 

1 

6 

1 

13 

•  •  • 

•  •  •  • 

40  to  49  years . 

5 

7 

2 

4 

2 

7 

•  •  • 

.... 

3 

26 

3 

53 

•  •  • 

•  •  •  • 

50  to  59  years . 

14 

31 

9 

23 

4 

21 

5 

25 

5 

82 

3 

101 

2 

64 

60  to  69  years . 

24 

97 

18 

82 

5 

51 

13 

108 

6 

208 

3 

227 

3 

191 

70  to  79  years . 

31 

297 

28 

296 

8 

203 

20 

362 

3 

301 

•  •  • 

•  •  •  • 

3 

506 

80  years  and  over.. 

17 

636 

16 

674 

4 

466 

12 

791 

1 

338 

. . . 

•  •  •  • 

1 

493 

Total  . 

354 

63 

252 

53 

114 

50 

138 

56 

102 

120 

50 

127 

52 

114 

LOBAR  PNEUMONIA. 


Under  1  year . 

91 

889 

59 

664 

32 

713 

27 

613 

32 

2374 

22 

3212 

10 

1504 

Betw.  1  and  2  years 

47 

489 

35 

412 

15 

342 

20 

488 

12 

1065 

5 

898 

7 

1228 

2  to  4  years . 

48 

149 

32 

114 

17 

121 

15 

108 

16 

385 

12 

596 

4 

187 

5  to  9  years . 

12 

24 

9 

21 

4 

18 

5 

23 

3 

47 

1 

33 

2 

60 

Under  10  years.... 

198 

195 

135 

152 

68 

152 

67 

152 

63 

483 

40 

634 

23 

342 

10  to  19  years . 

24 

23 

16 

18 

10 

23 

6 

13 

8 

58 

5 

85 

3 

38 

20  to  29  years . 

47 

42 

24 

26 

23 

52 

1 

2 

23 

112 

13 

144 

10 

86 

30  to  39  years . 

78 

87 

49 

67 

22 

62 

27 

71 

29 

183 

19 

248 

10 

123 

40  to  49  years . 

61 

89 

39 

68 

22 

80 

17 

57 

22 

193 

11 

195 

11 

192 

50  to  59  years . 

85 

188 

70 

179 

41 

217 

29 

144 

15 

247 

9 

304 

6 

193 

60  to  69  years . 

90 

363 

75 

342 

52 

526 

23 

191 

15 

519 

8 

606 

7 

446 

70  to  79  years . 

82 

784 

77 

814 

30 

762 

47 

852 

5 

502 

2 

496 

3 

506 

80  years  and  over . . 

40 

1498 

33 

1389 

13 

1515 

20 

1318 

7 

2365 

3 

3226 

4 

1970 

Total  . 

705 

126 

518 

109 

281 

123 

237 

97 

187 

220 

110 

279 

77 

168 

BRONCHITIS. 


Under  1  year . 

32 

313 

24 

270 

8 

178 

16 

363 

8 

593 

4 

584 

4 

602 

Betw.  1  and  2  years 

11 

114 

6 

71 

3 

68 

3 

73 

5 

444 

3 

539 

2 

351 

2  to  4  years . 

10 

31 

8 

29 

2 

14 

6 

43 

2 

48 

1 

50 

1 

47 

5  to  9  years . 

3 

6 

3 

7 

1 

5 

2 

9 

Under  10  years.... 

56 

55 

41 

46 

14 

31 

27 

61 

15 

115 

8 

127 

7 

104 

10  to  19  years . 

5 

5 

5 

36 

•  •  • 

•  •  •  • 

5 

63 

20  to  29  years . 

30  to  39  years . 

6 

7 

3 

4 

3 

8 

•  •  • 

•  •  •  • 

3 

19 

2 

26 

1 

12 

40  to  49  years . 

5 

7 

1 

2 

1 

4 

•  •  • 

•  •  •  • 

4 

35 

2 

35 

2 

35 

50  to  59  years . 

3 

7 

3 

8 

2 

11 

1 

5 

60  to  69  years . 

21 

85 

19 

87 

13 

132 

6 

50 

2 

69 

... 

•  •  •  • 

2 

128 

70  to  79  years . 

30 

287 

29 

307 

16 

406 

13 

236 

1 

100 

•  •  • 

•  •  •  • 

1 

169 

80  years  and  over. . 

31 

1161 

29 

1221 

7 

816 

22 

1450 

2 

676 

1 

1075 

1 

493 

Total  . 

157 

28 

125 

26 

56 

24 

69 

28 

32 

38 

13 

33 

19 

42 

table  that  the  general  course  of  the  curves  for  bronchitis  and  both  broncho- 
and  lobar  pneumonia  is  similar,  and  that  age  has  exerted  an  enormously 
important  influence  upon  the  rates  in  both  whites  and  negroes.  For  bron¬ 
chitis,  the  lower  rates  occur  in  whites  between  10  and  50  years  and  in  negroes 
between  20  and  40  years.  For  broncho-pneumonia,  the  lowest  death-rates 


370  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


fall  in  whites  between  20  and  60  years  and  in  blacks  between  20  and  50 
years.  In  this  affection,  as  officially  classified,  the  rates  show  a  drop  in  the 
third  decade  in  whites  and  in  the  fourth  decade  in  negroes,  and  for  bronchitis 
no  deaths  are  credited  to  negroes  in  the  third  and  fourth  decades  of  life.  In 
both  of  these  affections  the  death-rates  are  higher  under  the  tenth  year  in 
negroes  than  in  whites,  while  after  the  seventy-ninth  year  the  reverse  is  the 
case.  If  the  rates  for  bronchitis  and  broncho-pneumonia  were  combined,  on 
the  whole,  the  curve  of  the  plotted  figures  would  not  depart  materially  from 
that  for  broncho-pneumonia  alone. 

In  lobar  pneumonia,  as  in  the  other  two  affections  examined,  the  highest 
rates  are  met  with  at  the  extremes  of  age.  The  rates  for  negroes  are  con¬ 
siderably  higher  than  those  for  whites  throughout  the  life-span.  The  lowest 
rates  for  whites  lie  between  the  tenth  and  the  fiftieth  year  and  those  for  negroes 
between  the  tenth  and  the  thirtieth  year.  The  rates  for  negroes  are  at  all  ages 
uniformly  higher  than  those  for  whites.  In  both  races  there  is  a  little  change 
in  the  rates  between  the  fourth  and  fifth  decades.  While  the  rates  for  lobar 
pneumonia  are  lower  in  the  earlier  years  of  life,  they  are  higher  throughout 
than  those  for  broncho-pneumonia. 

The  courses  of  the  combined  rates  for  broncho-  and  lobar  pneumonia  show 
perhaps  more  accurately  the  relation  of  age  and  race  to  pneumonia  mortality. 
In  bronchitis,  the  female  total  rate  is  significantly  higher  than  the  male  in 
whites;  the  rate  for  males  is  greater  than  that  for  females  in  every  decade 
except  the  first  year  and  for  80  years  and  over.  In  the  colored,  the  female  rate 
is  20  per  cent  higher  than  the  male  rate  for  all  ages  and  for  each  decade  except 
the  first,  fourth,  fifth,  and  80  years  and  over.  There  were  no  deaths  in  colored 
males  in  the  second,  third,  sixth,  seventh,  and  eighth  decades.  For  broncho¬ 
pneumonia  in  whites,  the  total  female  rate  is  10  per  cent  greater  than  the 
male,  but  there  is  very  little  difference  in  the  rates  for  the  two  sexes  before 
the  seventh  decade,  after  which  the  rate  in  females  is  markedly  higher.  In 
the  colored,  the  total  rate  is  greater  in  males  by  10  per  cent  and  the  rates  are 
higher  in  this  sex  uniformly  until  the  seventh  decade,  after  which  the  rates  for 
females  are  not  markedly  in  excess.  In  lobar  pneumonia  the  total  rate  for 
males  is  21  per  cent  greater  than  that  for  females,  and  the  male  rate  exceeds 
the  female  rate  in  every  decade  except  the  fourth  and  over  70  years.  In  the 
negro,  the  male  rate  is  much  higher  in  the  first  four  decades.  In  the  sixth  and 
seventh  decades  and  80  years  and  over,  the  female  rates  are  higher.  In  the 
eighth  decade,  the  rates  for  the  two  sexes  are  equal.  For  the  whole  life-span, 
the  male  rates  are  36  per  cent  greater  than  the  female.  In  broncho-  and  lobar 
pneumonia  taken  together  for  whites,  the  rate  for  all  ages  is  11.5  per  cent 
greater  in  males,  in  whom  higher  rates  are  met  in  each  decade  except  the 
fourth  and  after  70  years,  when  the  rates  for  females  are  considerably  higher. 
In  the  colored  race,  the  rate  for  all  ages  is  30  per  cent  higher  in  males,  and 
the  rates  for  the  separate  decades,  except  after  the  seventh,  are  considerably 
higher  in  the  male. 

The  rates  for  the  same  categories  in  1920  (table  76),  which  differing  in  many 
respects  from  those  for  1910,  shows,  in  the  main,  very  much  the  same  propor¬ 
tional  distribution  of  mortality  by  age,  color  and  sex. 

When  on  the  basis  of  rates  specific  for  age  for  the  total  population,  for  whites 
and  for  negroes,  the  mortality  from  all  forms  of  pneumonia  and  from  all 


FEBRILE  DISEASES 


371 


Table  76. — Number  of  deaths,  and  rate  of  death ,  per  100,000  living  inhabitants,  from 
pneumonia  and  bronchitis,  according  to  age,  color,  and  sex,  for  1920. 

D  =  death.  It  =  rate. 

TOTAL  PNEUMONIA. 


Age-groups. 

Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

Under  I  year . 

275 

1852 

181 

1405 

95 

1439 

86 

1369 

94 

4776 

53 

5538 

41 

4055 

1  to  4  years . 

174 

319 

113 

235 

55 

228 

58 

242 

6.1 

952 

31 

996 

30 

911 

0  to  4  years . 

449 

647 

294 

482 

150 

488 

144 

332 

155 

1851 

84 

2064 

71 

1649 

5  to  9  years . 

32 

50 

24 

43 

14 

49 

10 

36 

8 

99 

6 

155 

2 

48 

0  to  9  years . 

481 

359 

318 

271 

164 

276 

154 

265 

163 

991 

90 

1135 

73 

858 

10  to  19  years . 

41 

33 

29 

27 

15 

28 

14 

25 

12 

75 

5 

71 

7 

79 

20  to  29  years . 

152 

105 

106 

89 

46 

78 

60 

100 

46 

178 

24 

197 

22 

161 

30  to  39  years . 

162 

132 

123 

122 

67 

133 

56 

112 

39 

179 

19 

172 

20 

186 

40  to  49  years . 

129 

140 

85 

111 

39 

102 

46 

119 

44 

283 

20 

241 

24 

329 

50  to  59  years . 

139 

222 

112 

205 

58 

217 

54 

193 

27 

344 

15 

353 

12 

332 

60  to  69  years . 

134 

372 

116 

356 

60 

392 

56 

325 

18 

519 

5 

292 

13 

742 

70  to  79  years . 

108 

749 

101 

773 

41 

733 

60 

804 

7 

516 

4 

661 

3 

399 

80  years  and  over. 

47 

135 

40 

128 

12 

599 

28 

1398 

7 

1977 

3 

2239 

4 

1818 

Total  . 

1393 

190 

1030 

165 

502 

163 

528 

167 

363 

334 

185 

348 

178 

321 

BRONCHOPNEUMONIA. 

Under  1  year . 

230 

1549 

148 

1149 

76 

1152 

72 

1146 

82 

4167 

47 

4911 

35 

3462 

1  to  4  years . 

127 

233 

81 

168 

39 

162 

42 

175 

46 

718 

24 

771 

22 

668 

0  to  4  years . 

357 

515 

229 

376 

115 

374 

114 

263 

128 

1528 

71 

1744 

57 

1324 

5  to  9  years . 

18 

28 

14 

25 

8 

28 

6 

22 

4 

50 

3 

78 

1 

24 

0  to  9  years . 

375 

280 

243 

207 

123 

207 

120 

207 

132 

803 

74 

933 

58 

681 

10  to  19  years . 

15 

12 

13 

12 

5 

9 

8 

15 

2 

13 

2 

28 

•  •  • 

•  •  •  • 

20  to  29  years . 

42 

29 

35 

29 

18 

31 

17 

28 

7 

27 

1 

8 

6 

44 

30  to  39  years . 

32 

26 

25 

25 

12 

24 

13 

26 

7 

32 

4 

36 

3 

28 

40  to  49  years . 

32 

35 

20 

26 

10 

26 

10 

26 

12 

77 

4 

48 

8 

110 

50  to  59  years . 

40 

64 

33 

60 

15 

56 

18 

64 

7 

89 

4 

94 

3 

83 

60  to  69  years . 

58 

161 

50 

154 

28 

183 

22 

128 

8 

231 

2 

117 

6 

342 

70  to  79  years . 

64 

444 

60 

459 

23 

411 

37 

496 

4 

295 

2 

331 

2 

266 

80  years  and  over. 

32 

92 

27 

86 

8 

399 

19 

949 

5 

1412 

2 

1493 

3 

1364 

Total  . 

690 

94 

506 

81 

242 

78 

264 

83 

184 

169 

95 

178 

89 

160 

LOBAR  PNEUMONIA 


Under  1  year . 

45 

303 

1  to  4  years . 

47 

86 

0  to  4  years . 

92 

133 

5  to  9  years . 

14 

22 

0  to  9  years . 

106 

79 

10  to  19  years . 

26 

21 

20  to  29  years . 

110 

76 

30  to  39  years . 

130 

106 

40  to  49  years . 

97 

105 

50  to  59  years . 

99 

158 

60  to  69  years . 

76 

211 

70  to  79  years . 

44 

305 

80  years  and  over. 

15 

43 

Total  . 

703 

96 

33 

256 

19 

288 

14 

223 

32 

67 

16 

66 

16 

67 

65 

107 

35 

114 

30 

69 

10 

18 

6 

21 

4 

14 

75 

64 

41 

69 

34 

59 

16 

15 

10 

19 

6 

11 

71 

60 

28 

48 

43 

71 

98 

97 

55 

109 

43 

86 

65 

85 

29 

76 

36 

93 

79 

144 

43 

161 

36 

128 

66 

203 

32 

209 

34 

197 

41 

314 

18 

322 

23 

308 

13 

42 

4 

200 

9 

449 

524 

84 

260 

84 

264 

83 

12 

610 

6 

627 

6 

593 

15 

234 

7 

225 

8 

243 

27 

322 

13 

319 

14 

325 

4 

50 

3 

78 

1 

24 

31 

189 

16 

202 

15 

176 

10 

63 

3 

42 

7 

79 

39 

151 

23 

189 

16 

117 

32 

147 

15 

136 

17 

158 

32 

205 

16 

193 

16 

219 

20 

255 

11 

259 

9 

249 

10 

289 

3 

175 

7 

400 

3 

221 

2 

331 

1 

133 

2 

565 

1 

746 

1 

455 

179 

165 

90 

169 

89 

160 

372  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


Table  76. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from 

pneumonia  and  bronchitis,  etc. — Continued. 

BRONCHITIS. 


White. 


Colored. 


Age-groups. 

loiai* 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

Under  1  year . 

34 

229 

22 

171 

11 

167 

11 

175 

12 

610 

7 

731 

5 

495 

1  to  4  years . 

13 

24 

6 

12 

3 

12 

3 

13 

7 

109 

3 

96 

4 

121 

0  to  4  years . 

47 

68 

28 

46 

14 

46 

14 

32 

19 

227 

10 

246 

9 

209 

5  to  9  years . 

2 

3 

I 

2 

1 

3 

•  •  • 

•  •  •  • 

1 

12 

1 

26 

•  •  • 

•  •  •  • 

0  to  9  years . 

49 

37 

29 

25 

15 

25 

14 

24 

20 

122 

11 

139 

9 

106 

10  to  IQ  vpara 

1 

1 

1 

6 

1 

14 

20  to  29  years . 

1 

1 

1 

1 

1 

2 

30  to  39  years . 

5 

4 

4 

4 

1 

2 

3 

6 

1 

5 

•  •  • 

•  •  •  • 

1 

9 

40  to  49  vears . 

1 

1 

1 

1 

1 

3 

50  to  59  years . 

2 

3 

2 

4 

2 

7 

60  to  69  years . 

5 

14 

4 

12 

•  •  • 

•  •  •  • 

4 

23 

1 

29 

•  •  • 

•  •  •  • 

1 

57 

70  t.o  79  years . 

7 

49 

7 

54 

3 

54 

4 

54 

80  years  and  over. 

13 

37 

12 

38 

4 

200 

8 

399 

1 

282 

1 

746 

•  •  • 

•  •  •  • 

Total  . 

84 

11 

60 

10 

26 

8 

34 

11 

24 

22 

13 

24 

11 

20 

causes  of  death  in  1920  are  compared  (tables  76  and  136,  graph  20)  the  shapes 
of  the  respective  curves  from  the  first  to  the  eighth  decade  of  life  are  strikingly 
similar.  In  all  there  is  the  same  marked  drop  in  the  second  decade  from  the  high 
level  of  the  first,  with  a  decided  rise  in  the  third  decade.  For  the  total  popula¬ 
tion  the  rates  ascend  in  much  the  same  degree  from  the  third  to  the  seventh 
decade  of  life.  The  mortality  from  pneumonia  fails  to  rise,  in  negroes,  between 
the  third  to  the  fourth,  and,  in  whites,  between  the  fourth  and  fifth  decades, 
and  after  the  seventy-ninth  year  the  pneumonia-rate  falls  in  whites  and  rises 
in  negroes.  With  these  minor  exceptions,  however,  the  parallelism  is  very 
close.  Remarkably  similar  agreements  exist  also  in  the  course  of  rates  specific 
for  sex  and  age.  While  the  rates  for  all  causes  include,  of  course,  those  for 
pneumonia,  the  latter  bear  too  small  a  proportion  to  the  whole  to  seriously 
vitiate  the  comparison.  It  would  appear,  then,  that  the  risk  of  dying  in  the 
various  decades  of  life  from  pneumonia  varied  directly  with  the  risk  of  dying 
from  some  one  of  all  the  remaining  causes  of  death,  i.  e.,  of  dying  at  all. 

But  the  category  all  forms  of  pneumonia  consists  of  at  least  two  very  dis¬ 
tinctly  different  elements.  Lobar  pneumonia  differs  from  broncho-pneumonia 
(including  bronchitis)  in  two  essential  features,  namely,  that  it  is  both  etio- 
logically  and  pathologico-anatomically  a  specific  disease.  Broncho-pneumonia 
represents,  on  the  other  hand,  a  heterogeneous  congeries  of  acute  lung  infections 
caused  by  a  variety  of  pyogenic  organisms.  Therefore,  these  two  forms  of 
pneumonia  must  be  considered  separately.  For  this  purpose  their  courses  in 
rates  specific  for  age  for  the  whole  population  are  compared  with  that  for  all 
causes  of  death  on  graph  20. 

It  is  evident  that  during  the  first  10  years  of  life,  though  on  widely  different 
levels  (the  mortality  from  broncho-pneumonia  being  much  higher  than  that 
from  lobar  pneumonia),  the  rates  for  both  these  affections  exhibit  the  charac¬ 
teristics  of  such  acute  specific  infections  as  scarlet  fever,  measles,  whooping- 
cough,  and  diphtheria.  They  are  both  characterized  by  high  rates  during  the 
first  and  by  low  rates  during  the  second  decade  of  life.  Unlike  the  specific 
infections  above  mentioned,  both  forms  of  pneumonia  show  rising  rates  after 


FEBRILE  DISEASES 


373 


the  second  decade  of  life.  As  between  themselves,  however,  there  are  marked 
differences  in  degree  of  lethal  force.  The  mortality  for  broncho-pneumonia 
is  much  greater  in  the  first  and  much  less  in  the  second  decade  than  that 
for  lobar  pneumonia.  The  mortality  for  the  latter  rises  to  a  higher  level  in  the 
third  decade  (when  it  is  nearly  as  high  as  in  the  first)  and,  except  for  a  stand¬ 
still  between  40  and  49  years,  continues  to  mount  by  gradual  steps  up  to  the 
eightieth  year.  With  broncho-pneumonia,  on  the  other  hand,  the  rate  of  mor¬ 
tality,  after  remaining  stationary  on  a  very  low  level  between  the  thirtieth 
and  forty-ninth  years  of  life,  rises  comparatively  abruptly  and  in  the  eighth 
decade  far  surpasses  that  for  lobar  pneumonia.  After  the  seventy-ninth  year  of 
life  the  mortality  for  both  forms  of  pneumonia  falls  notably,  but  the  rate  for 
broncho-pneumonia  is  more  than  double  that  for  lobar  pneumonia. 


Graph  20  (from  tables  76  and  136).  Comparison  of  mortality-rates  specific 
for  age  from  total  pneumonia  and  from  lobar  and  broncho-pneumonia,  and 
from  all  causes  of  death,  in  1920. 

As  compared  with  the  course  of  the  rates  for  deaths  from  all  causes,  broncho¬ 
pneumonia  conforms  more  closely  during  the  first  10  years  and  lobar  pneu¬ 
monia  during  the  remainder  of  life.  In  respect  to  the  influence  of  age 
upon  rate  of  mortality,  therefore,  both  these  two  forms  of  pneumonia  depart 
in  a  striking  manner  from  the  other  acute  febrile  diseases  for  which  local 
data  for  comparison  exist,  and  as  between  each  other  they  present  certain 
marked  differences. 

Broncho-pneumonia  furnishes  an  example  of  the  influence  of  age,  or 
rather  of  the  qualities  that  vary  with  age,  upon  the  resistance  of  the  lungs 
to  fatal  infection  with  the  pyogenic  bacteria  as  a  group.  This  resistance  is 
peculiarly  weak  in  the  extremes  of  life  and  particularly  strong  between  5 
and  50  years  of  age.  With  lobar  pneumonia  the  resistance  to  death  is  only 
relatively  weak  in  the  first  5  years  of  life,  high  from  the  fifth  to  the  nine- 


374  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


teenth  year  and  thereafter  steadily  and  notably  decreasing  until  the  eightieth 
year.  In  this  latter  period  its  course  of  mortality  closely  parallels  that  for  all 
causes  of  death.  In  these  respects  lobar  pneumonia  is  unique  among  the 
specific  febrile  diseases  analyzed  in  this  material. 

As  exposure  to  pneumonia  is  in  general  terms  not  selective,  these  phe¬ 
nomena  suggest  among  other  things  that  the  forces  of  natural  immunity 
which  participate  in  the  control  of  mortality  from  lobar  and  broncho-pneu¬ 
monia  in  the  various  age-periods  differ,  in  part  at  least,  in  their  seats  or  in 
their  modes  of  action.  The  fact  that  the  age  distribution  of  mortality  from 
lobar  pneumonia  follows  so  closely  the  path  of  all  causes  of  death,  and  there¬ 
fore  seems  to  be  more  intimately  associated  with  general  constitutional  vigor, 
suggests  that  for  this  type  of  pneumonia  natural  resistance  is  mainly  gen¬ 
eral  or  constitutional  rather  than  local.  The  in  some  respects  contrary 
behavior  of  mortality  for  the  non-specific  broncho-pneumonia  provokes  the 
suggestion  that  the  chief  seat  of  resistance  is  local,  i.  e.,  in  the  lungs.  These 
aberrations  do  not,  however,  warrant  the  view  that  general  constitutional 
resistance  plays  no  part  in  the  one  disease  and  local  resistance  is  unim¬ 
portant  in  the  other,  but  they  do  indicate  that  as  between  the  two  affections 
there  are  differences  in  this  regard.  It  is  a  significant  fact  that  for  lobar 
pneumonia  the  relative  immunity  from  death  acquired  by  the  individual 
after  passing  through  infancy  and  childhood  to  puberty,  a  quality  which 
it  shares  with  so  many  acute  specific  infections,  is,  contrary  to  what  ob¬ 
tains  with  them,  no  higher  in  the  third  than  in  the  first  decade,  and  after 
this  period  steadily  diminishes  during  the  remainder  of  life.  Of  signifi¬ 
cance  also  is  the  behavior  of  resistance  of  the  individual  to  death  from 
lung  infection  with  the  mixture  of  pyogenic  bacteria  concerned  with  the 
causation  of  broncho-pneumonia,  as  exemplified  by  the  low  death-rate  be¬ 
tween  the  tenth  and  the  forty-ninth  years,  with  the  marked  rise  into  the 
period  of  old  age. 

Pneumonia,  both  lobar  and  broncho,  was  made  reportable  in  1917,  but 
the  reporting  of  cases  has  not  been  complete  enough  for  definite  conclusions 
in  regard  to  case  fatality.  The  cases  reported  in  1921  were  tabulated  ac¬ 
cording  to  color,  sex,  and  age.  While,  perhaps,  they  were  not  all  cases  of 
primary  pneumonia,  and  in  number  they  certainly  fall  short  of  actual  oc¬ 
currence  (there  were  only  2,095  cases  as  compared  with  1,001  deaths,  and 
the  death  certificates  were  not  cross-checked  with  the  cards  of  reported  cases 
in  order  to  add  to  the  list  of  the  latter  individuals  recorded  as  dying  of 
pneumonia  but  not  reported  as  cases  previous  to  death),  their  proportional 
distribution  according  to  these  three  categories  is  probably  accurate  enough 
to  justify  comparison  of  the  specific  rates  presented  in  table  77. 

It  will  be  observed  that  in  their  general  trend  the  morbidity-rates  for 
the  various  categories  agree  with  the  corresponding  mortality  rates  for  1920. 
For  all  forms  of  pneumonia  and  for  both  lobar  and  broncho-pneumonia  the 
morbidity-rates  of  the  population  at  all  ages  are  higher  in  negroes  than 
in  whites  and  in  females  than  in  males  of  both  races.  In  the  first  twenty 
years  of  life  the  age  distribution  of  cases  also  agrees  closely  in  trend  with 
that  for  deaths  in  1920.  In  the  third  decade  of  life  morbidity  decreases 
in  the  white  and  increases  in  the  negro.  There  is  a  gradual  rise  in  the 
rates  in  whites  during  the  third  and  fourth  and  in  negroes  from  the  third 


FEBRILE  DISEASES 


375 


Table  77. — Number  of  cases  and  rate  of  morbidity ,  per  100J000  living  inhabitants,  in 
1920,  from  pneumonia,  according  to  age,  color,  and  sex,  in  1921 

C  =  cases.  R  =  rate. 

TOTAL  PNEUMONIA. 


White. 


Colored. 


Age-groups. 

luiai. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

c 

R 

C 

R 

C 

R 

C 

R 

C 

R 

C 

R 

C 

R 

Under  1  year . 

253 

1703 

201 

1560 

110 

1667 

91 

1448 

52 

2642 

23 

2403 

29 

2868 

1  to  4  years . 

445 

816 

378 

786 

204 

845 

174 

726 

67 

1046 

33 

1060 

34 

1032 

0  to  4  years . 

698 

1006 

579 

949 

314 

1021 

265 

611 

119 

1421 

56 

1376 

63 

1463 

5  to  9  years . 

232 

360 

211 

374 

128 

448 

83 

298 

21 

260 

13 

337 

8 

190 

0  to  9  vears . 

930 

695 

790 

673 

442 

745 

348 

599 

140 

851 

69 

870 

71 

834 

10  to  19  years . 

192 

155 

159 

148 

105 

199 

54 

98 

33 

207 

16 

226 

17 

191 

20  to  29  years . 

194 

134 

136 

114 

78 

133 

58 

96 

58 

225 

35 

287 

23 

169 

30  to  39  years . 

185 

151 

128 

127 

62 

123 

66 

132 

57 

261 

39 

353 

18 

167 

40  to  49  years . 

150 

162 

105 

137 

64 

168 

41 

106 

45 

289 

26 

314 

19 

261 

50  to  59  years . 

154 

246 

128 

234 

71 

266 

57 

203 

26 

331 

12 

283 

14 

387 

60  to  69  years . 

146 

405 

123 

378 

57 

372 

66 

383 

23 

664 

11 

642 

12 

685 

70  to  79  years . 

111 

770 

102 

781 

35 

625 

67 

898 

9 

664 

5 

826 

4 

533 

80  years  and  over. 

33 

95 

31 

99 

12 

599 

19 

949 

2 

565 

•  •  • 

.... 

2 

909 

Total  . 

2095 

285 

1702 

272 

926 

300 

776 

245 

393 

362 

213 

400 

180 

325 

BRONCHO-PNEUMONIA. 

Under  1  year . 

214 

1441 

170 

1319 

92 

1394 

78 

1241 

44 

2236 

21 

2194 

23 

2275 

1  to  4  years . 

311 

571 

260 

540 

134 

555 

126 

526 

51 

796 

25 

803 

26 

789 

0  to  4  years . 

525 

757 

430 

705 

226 

735 

204 

471 

95 

1134 

46 

1130 

49 

1138 

5  to  9  years . 

123 

191 

109 

193 

67 

234 

42 

151 

14 

174 

9 

233 

5 

119 

0  to  9  years . 

648 

484 

539 

459 

293 

494 

246 

424 

109 

663 

55 

693 

54 

634 

10  to  19  years . 

66 

53 

51 

47 

38 

72 

13 

24 

15 

94 

8 

113 

7 

79 

20  to  29  years . 

58 

40 

43 

36 

17 

29 

26 

43 

15 

58 

9 

74 

6 

44 

30  to  39  years . 

64 

52 

45 

45 

15 

30 

30 

60 

19 

87 

13 

118 

6 

56 

40  to  49  years . 

60 

65 

40 

52 

20 

52 

20 

52 

20 

128 

12 

145 

8 

110 

50  to  59  years . 

73 

117 

56 

102 

31 

116 

25 

89 

17 

216 

8 

188 

9 

249 

60  to  69  years . 

62 

172 

49 

151 

23 

150 

26 

151 

13 

375 

6 

350 

7 

400 

70  to  79  years . 

73 

506 

64 

490 

25 

447 

39 

523 

9 

664 

5 

826 

4 

533 

80  years  and  over. 

22 

63 

20 

64 

9 

449 

11 

549 

2 

565 

•  •  •  • 

2 

909 

Total  . 

1126 

153 

907 

145 

471 

153 

436 

138 

219 

201 

116 

218 

103 

186 

LOBAR  PNEUMONIA. 

Under  1  year . 

39 

263 

31 

241 

18 

273 

13 

207 

8 

407 

2 

209 

6 

593 

1  to  4  years . 

134 

246 

118 

245 

70 

290 

48 

200 

16 

250 

8 

257 

8 

243 

0  to  4  years . 

173 

249 

149 

244 

88 

286 

61 

141 

24 

287 

10 

246 

14 

325 

5  to  9  years . 

109 

169 

102 

181 

61 

213 

41 

147 

7 

84 

4 

104 

3 

71 

0  to  9  years . 

282 

211 

251 

214 

149 

251 

102 

176 

31 

189 

14 

177 

17 

200 

10  to  19  years . 

126 

102 

108 

100 

67 

127 

41 

75 

18 

113 

8 

113 

10 

113 

20  to  29  years . 

136 

94 

93 

78 

61 

104 

32 

53 

43 

166 

26 

213 

17 

125 

30  to  39  years . 

121 

99 

83 

83 

47 

93 

36 

72 

38 

174 

26 

235 

12 

111 

40  to  49  years . 

90 

97 

65 

85 

44 

115 

21 

54 

25 

161 

14 

169 

11 

151 

50  to  59  years . 

81 

129 

72 

132 

40 

150 

32 

113 

9 

115 

4 

94 

5 

138 

60  to  69  years . 

84 

233 

74 

227 

34 

222 

40 

232 

10 

289 

5 

292 

5 

285 

70  to  79  years . 

38 

264 

38 

291 

10 

179 

28 

375 

80  years  and  over. 

11 

32 

11 

35 

3 

150 

8 

399 

Total  . 

969 

132 

795 

127 

455 

148 

340 

107 

174 

160 

97 

182 

77 

139 

376  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

to  the  sixth  decade,  inclusive.  The  rate  in  the  white  ascends  sharply  in  the 
sixth,  seventh,  and  eighth  decades,  and  in  the  negro  in  the  seventh  decade. 
In  the  latter  there  is  little  change  in  the  level  of  the  rate  after  the  sixty- 
ninth  year,  while  in  the  white  the  rate  falls  sharply  after  the  seventy-ninth 
year  of  life;  morbidity  is  considerably  higher  in  the  negro  at  every  age- 
period  up  to  the  eightieth  year,  but  the  difference  is  most  marked  between 
the  thirtieth  and  the  fiftieth  years. 

Among  whites  the  incidence  of  pneumonia  is  higher  in  males  than  in 
females  in  every  age-period  except  the  fourth  decade  and  after  the  sixty- 
ninth  year,  while  in  the  negro  it  is  higher  in  males  throughout  life  except 
in  the  sixth,  seventh,  and  eighth  decades.  This  disparity  between  the  rates  for 
males  and  females  is  greatest  among  whites  in  the  first  three  decades  and  among 
negroes  in  the  third,  fourth,  and  eighth  decades. 

It  is  notable  that  while  the  difference  in  incidence  for  broncho-  and  lobar 
pneumonia  in  the  population  as  a  whole  at  all  ages  is  not  great,  the  rates  being 
153  and  138,  respectively,  the  proportional  distribution  of  morbidity  rela¬ 
tive  to  the  different  age-groupings  varies  widely.  In  both  the  rates  of  mor¬ 
bidity  are  considerably  higher  in  negroes  than  in  whites  and  in  males  than 
in  females  of  both  races.  As  with  the  mortality  in  1920,  the  morbidity-rate 
for  broncho-pneumonia  in  1921  is  very  high  in  the  first  decade.  It  recedes, 
however,  sharply  in  the  second,  falls  still  lower  in  the  third,  and  remains  rela¬ 
tively  low  during  the  fourth  and  fifth  decades.  After  the  forty-ninth  year  the 
rate  of  incidence  rises  steadily  to  a  peak  in  the  eighth  decade  and  then  falls 
abruptly  during  the  remainder  of  life.  In  every  age  period  the  rate  is  con¬ 
siderably  higher  among  negroes  than  among  whites.  Among  the  latter  the 
rate  for  males  exceeds  that  for  females  in  the  first,  second,  sixth,  and  eighth 
decades  and  eighty  years  and  over,  while  in  the  third,  fourth,  and  fifth  decades 
the  case  is  reversed.  Among  negroes  the  rate  of  incidence  is  higher  in  males, 
except  in  the  sixth  and  seventh  decades. 

For  lobar  pneumonia  in  the  population  as  a  whole,  from  a  relatively  high 
level  for  the  first  decade  of  life,  the  morbidity-rate  falls  markedly  in  the 
second  then  slightly  again  to  its  lowest  point  in  the  third  decade.  There 
is  but  little  fluctuation  in  the  rate  in  the  30  years  between  the  twentieth  and 
the  forty-ninth  years  of  age.  After  the  fiftieth  year  the  rise  in  morbidity 
is  gradual  and  the  peak  is  attained  in  the  eighth  decade,  after  which  the 
rate  declines  sharply.  In  general  trend  the  course  of  the  rate  for  whites 
departs  but  slightly  from  that  of  the  total  rate.  In  the  negro  the  course  of 
recorded  morbidity  shows  distinct  differences.  Somewhat  lower  in  the  first 
two  decades  of  life  than  the  rate  for  whites,  it  ascends  abruptly  in  the  third 
decade  to  a  relatively  high  level,  which  is  maintained  with  little  deviation 
until  the  fiftieth  year  of  life.  The  rate  falls  in  the  sixth  decade  to  the 
level  of  the  second,  but  rises  again  in  the  seventh.  No  cases  were  reported 
among  negroes  over  the  sixty-ninth  year  of  age. 

Among  whites  the  rate  is  higher  in  males  than  in  females  until  the  sixty- 
ninth  year,  after  which  the  reverse  is  true.  The  rates  for  the  two  sexes, 
however,  follow  in  general  the  same  trend.  Among  negroes  the  rate  is 
higher  for  males  than  for  females  in  every  decade  except  the  first,  sixth,  and 
seventh.  But  in  the  third,  fourth,  and  fifth  decades  the  trends  of  the  two 


FEBRILE  DISEASES 


377 


are  quite  different.  The  male  rate  runs  to  a  high  peak  in  the  third  and 
fourth  decades,  and  then  falls  in  the  fifth  and  sixth  decades,  to  rise  again  in 
the  seventh.  The  rate  for  negro  males  is  nearly  as  high  in  the  fourth  as  in 
the  first  decade.  These  irregularities  in  the  course  of  the  rates  for  negroes 
are  probably  in  large  degree  the  result  of  inadequate  case  reporting. 

In  the  main,  however,  the  striking  differences  in  the  trends  of  the  rates 
for  broncho-  and  lobar  pneumonia  observed  in  connection  with  mortality  are 
reflected  in  the  morbidity-rates  as  well.  In  so  far  as  may  be  judged  from 
this  material,  it  would  appear  that  in  lobar  pneumonia  the  risk  of  contract¬ 
ing  the  disease  varies  hardly  at  all  between  the  nineteenth  and  the  forty- 
ninth  years,  while  the  risk  of  dying  from  it  rises  progressively  between  the 
twentieth  and  thirty-ninth  years,  remains  unchanged  between  the  fortieth 
and  forty-ninth  years,  and  thereafter  increases  with  much  the  same  propor¬ 
tion  as  does  morbidity.  With  broncho-pneumonia,  on  the  other  hand,  ex¬ 
cept  in  the  second  decade  of  life,  the  risks  of  incidence  and  of  death  in  the 
various  age-groups  follow  the  same  trend  in  all  the  age-groups. 

On  the  whole,  the  trends  of  morbidity-rates  specific  for  age,  color,  and 
sex  for  total  pneumonia,  and  for  lobar  and  broncho-pneumonia  separately, 
in  1921  follow  closely  those  of  the  corresponding  rates  for  mortality  in 
1920.  The  agreement  in  respect  to  the  variation  with  age  of  the  qualities 
which  control  resistance  to  lobar  and  broncho-pneumonia  and  the  specific 
differences  in  natural  immunity  of  individuals  toward  these  two  kinds  of 
acute  lung  infection  support  the  implications  in  these  regards  derived  from 
the  study  of  mortality  alone. 


SUMMARY. 

The  curve  for  total  annual  mortality-rates  from  the  acute  inflammatory 
affections  of  the  respiratory  tract  (table  60,  graph  17)  is  marked  through¬ 
out  most  of  its  course  by  rather  wide  fluctuations.  Some  of  these  are 
short  and  cover  only  from  one  to  three  years,  while  others  extend  over  a 
long  sweep  of  years.  The  first  are  particularly  common  before  1840,  and 
are  usually  associated  with  corresponding  variations  in  the  rates  for  each 
member  of  the  group.  They  are  particularly  wide  for  whooping-cough.  The 
second  type  occurs  when,  owing  to  the  gradually  diminishing  importance 
of  the  latter  disease  and  the  steadily  rising  rates  for  diphtheria  and  pneu¬ 
monia,  the  curve  for  the  total  rates  tends  to  grow  smoother. 

Two  distant,  though  irregular,  waves  in  the  curve  for  the  total  rate  appear 
before  1840.  The  first,  beginning  in  1812,  reached  a  peak  with  a  rate  of  449 
in  1816,  and  declined  to  a  low  level  with  a  rate  of  95  in  1831.  The  second, 
starting  in  1832  and  with  its  peak  of  273  in  1833,  subsided  in  1840  to  a  rate 
of  116.  The  next  year  the  curve  for  the  total  rates  again  began  to  ascend  and 
by  1848  had  reached  315. 

From  this  level  the  departure  was  very  slight  until  after  1875.  By  1882  the 
rate  had  reached  478,  and  from  this  point  there  was  a  gradual  decline  to  253  in 
1889.  Between  1891  and  1903  the  total  rate  was  almost  constantly  above  300 
and  in  several  years  surpassed  375.  Then  there  was  a  gradual  descent  to  lower 
levels,  but  never  under  200,  until  1918,  when  in  connection  with  the  influenza — 
pneumonia  epidemic  and  some  increase  of  the  whooping-cough  rate,  the  total 


378  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

rate  rose  to  658.  The  next  year,  however,  the  rate  fell  to  222.  After  1885,  the 
shape  of  the  curve  of  the  total  rates  was  in  ever-increasing  degree  determined 
by  the  rates  for  pneumonia. 

It  is,  however,  from  the  curve  of  the  rates  as  averaged  for  5-year  periods 
(table  61,  graph  18)  that  the  clearest  picture  of  the  course  of  these  affections 
is  obtained.  Starting  with  a  rate  of  318  in  1812-1815  and  declining  slightly 
by  1820,  the  total  rate  dropped  decidedly  in  1821-1825  to  171.  Five  years 
later  it  had  fallen  to  152,  the  lowest  level  ever  attained.  This  fall  was  due  to 
declines  in  the  rates  for  each  member  of  the  group.  From  1835  the  total  rate 
ascended  by  gradual  steps  to  309  in  1851-1855.  This  change  was  brought 
about  entirely  by  increases  in  the  rates  for  pneumonia  and  diphtheria;  the 
rate  for  whooping-cough  was  practically  stationary.  After  falling  slightly 
during  the  next  10  years,  due  to  a  sharp  decline  in  the  diphtheria  rate,  the 
total  rate  rose  gradually  to  its  highest  level,  418,  in  1881-1885.  This  was 
associated  with  an  almost  unbroken  rise  in  the  pneumonia  rate  and  a  sudden 
and  great  rise  in  that  for  diphtheria  during  the  last  10  years.  In  1881-1885 
the  rates  for  each  of  these  two  diseases  stood  almost  at  the  same  level,  i.  e., 
about  200.  By  1880,  the  rate  for  whooping-cough  had  declined  conspicu¬ 
ously,  and  in  1881-1885  was  only  21.  Due  to  an  abrupt  fall  in  the  rates  for 
diphtheria  and  whooping-cough,  which  more  than  overbalanced  the  steady 
rise  in  the  pneumonia  rate,  the  total  rate  declined  to  319  in  1886-1890.  Its 
rise  to  363  in  1891-1895  was  owing  entirely  to  the  continued  ascent  in  the 
pneumonia  rate.  From  this  level  the  rate  declined  continuously  to  244  in 
1911-1915.  During  these  20  years  the  rates  for  all  the  members  of  the  group 
fell  decidedly,  though  not  always  at  the  same  time.  Owing  almost  entirely  to 
a  rise  in  the  pneumonia  rate,  the  total  rate  rebounded  to  332  in  1916-1920. 
The  total  rate,  therefore,  fell  continuously  and  decidedly  between  1812  and 
1830  from  a  high  to  a  very  low  level.  During  the  succeeding  55  years  the  rate 
rose  to  its  highest  peak  in  1881-1885,  and  from  this  point  declined,  with  but 
one  interruption,  until  1911-1915. 

From  this  detailed  account  of  the  behavior  of  this  group  of  diseases,  certain 
important  considerations  are  evident.  No  attempts  at  artificial  interference 
with  the  progress  of  pneumonia  have  ever  been  made  in  Baltimore.  Such 
attempts  of  this  nature  against  whooping-cough  as  have  been  made  during 
the  past  20  years  have  proven  fruitless.  It  has  been  shown  that  coincidently 
with  the  use  of  improved  methods  of  treatment  (intubation  about  1890  and 
antitoxin  since  1897,  particularly  since  1900),  the  mortality-rate  from  diph¬ 
theria  has  fallen  markedly.  Therefore,  the  courses  run  by  pneumonia  and 
whooping-cough  for  108  years  and  for  diphtheria  for  78  years  reflect  fairly  accu¬ 
rate  pictures  of  their  natural  reaction  on  this  population.  Here  is  another  clear- 
cut  example  over  a  long  period  of  the  reaction  of  an  organ  system  to  its 
most  serious  acute  infective  diseases.  After  a  century  of  experiment,  it  ends 
up  as  concerns  the  group  as  a  whole  no  better  than  it  began,  i.  e.,  with  death- 
rates  at  about  the  same  level.  Since  their  mortality-rates  have  differed  widely 
during  this  time,  it  is  evident  that  either  the  lethal  force  of  each  or  the  char¬ 
acter  of  the  natural  resistance  of  the  population,  or  both,  have  varied  not  once 
but  several  times. 

How  much  these  changes  in  the  courses  of  mortality  were  due  to  variations 
in  the  virulence  of  the  organisms,  to  the  differences  in  the  resistance  of  the 


FEBRILE  DISEASES 


379 


various  race  stocks  present  in  the  population  at  different  times,  to  the  changes 
in  the  age  distribution  of  those  exposed,  and  to  the  modification  in  the 
environment,  it  is  difficult  to  estimate  with  accuracy. 

Concerning  one  member  of  this  group,  whooping-cough,  this  question  can 
be  answered  with  some  degree  of  definitiveness.  The  lethal  force  of  this 
disease,  after  exhibiting  a  considerable  accession  between  1812  and  1820,  had, 
by  1825,  sunk  to  its  previous  level,  and  from  this  time  it  varied  only  within 
comparatively  narrow  limits  until  1880.  During  this  period  of  68  years  very 
profound  changes  in  the  population  and  in  the  environment  had  occurred. 
From  1880  to  1900,  also  a  period  of  considerable  changes  in  the  environment, 
its  lethal  force  sank  to  a  yet  lower  level,  about  which  it  has  tended  to  stabilize, 
in  a  population  whose  racial  composition  underwent  notable  changes.  Since 
1825,  the  mortality-rates  of  whooping-cough  have  varied  for  only  a  short 
period  between  1860  and  1870,  directly  with  those  of  pneumonia,  its  most 
important  lethal  complication.  No  variety  of  medical  treatment  has  been 
shown  to  influence  either  the  duration  or  the  severity  of  the  disease.  There¬ 
fore,  as  it  appears  that  the  variations  in  the  lethal  capacity  of  whooping- 
cough  are  not  directly  correlated  with  changes  in  population  composition, 
modifications  of  the  environment,  or  medical  treatment,  the  evidence  at  hand 
goes  to  show  that  they  must  lie  primarily  in  modifications  in  its  specific  cause. 
From  considerations  already  brought  forward,  it  would  appear  that  with 
decrease  in  lethal  force,  the  disease  has  made  decided  gains  in  invasive 
capacity. 

Under  the  same  conditions,  the  course  of  mortality  for  diphtheria  followed 
very  much  the  same  course  as  whooping-cough  until  1845.  For  the  next  20 
years,  in  association  with  very  definite  changes  of  both  population  and 
environment,  the  lethal  force  of  diphtheria  increased  markedly.  In  the  10 
years  from  1866  to  1875  the  mortality  sank  decidedly,  only,  however,  to  rise 
in  the  next  10  years  to  an  unprecedented  level.  Its  abrupt  fall  between  1885 
and  1890,  to  a  level  held  for  the  succeeding  10  years,  during  a  period  of  con¬ 
siderable  change  in  the  population  composition,  was  as  striking  as  the  previous 
rise.  As  intubation  can  hardly  be  held  responsible  for  more  than  a  small  part 
of  the  change  in  the  mortality-rates  during  the  last  phase,  the  period  of 
untrammeled  course  for  diphtheria  may  for  practical  purposes  be  taken  as  88 
years.  As  the  course  of  this  disease  has  often  varied  directly  with  changes  in 
the  population  composition  and  the  environment,  variations  of  its  lethal  force 
can  not  be  ascribed  wholly  to  modifications  in  its  causal  agent.  The  fact  that 
diphtheria  mortality-rates  have  varied  widely  from  time  to  time  (associated 
often  with  the  presence  or  absence  of  epidemics)  in  countries  with  fairly 
homogeneous  populations  and  in  rural  districts  where  population  changes 
of  this  type  have  been  gradual  or  even  absent  and  where  environmental  condi¬ 
tions  tend  to  remain  constant,  suggests  that  variability  in  the  virulence  of 
B.  diphtherice  has  been  the  chief  cause  of  variations  in  the  mortality-rates. 
It  is  well  established  by  laboratory  observation  and  experiment  that  the 
virulence  of  B.  diphtherice  often  changes  under  the  influence  of  a  variety  of 
modifications  of  environment,  but  the  conditions  under  which  it  is  grown  are 
too  highly  artificial  to  warrant  too  close  a  comparison  with  what  occurs  under 
natural  conditions. 

25 


380  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

With  the  acute  pulmonary  diseases,  with  their  diversities  of  etiology  and 
pathology,  the  case  is  more  complicated.  Certain  it  is  that  having  fallen  to 
a  low  level  by  1830,  the  rate  rose  strikingly  from  1845  to  1855,  during  a 
period  of  rapid  and  fundamental  changes  in  population  and  environment. 
However,  it  fell  as  markedly  during  the  next  10  years  without  any  considerable 
change  in  either.  From  1865  to  1895  the  progress  of  the  mortality-rate  was 
steadily  upward,  and  from  1895  to  1910  it  was  as  steadily  downward,  in  face 
of  decided  population  changes  in  both  periods.  With  no  particular  changes 
in  the  race  composition  of  the  population  and  greater  changes  in  the  environ¬ 
ment  that  previous  years  had  witnessed,  the  rate  was  stationary  from  1910 
to  1915,  and  then  rose  sharply  in  the  last  5-year  period.  From  this  picture  it 
would  appear  that  whatever  the  influence  of  other  factors,  the  changes  in  the 
mortality-rates  from  the  pneumonia  diseases  are  not  independent  of  varia¬ 
tions  in  the  virulence  of  one  or  more  of  their  causal  agents. 

Among  the  factors  responsible  for  the  fall  in  mortality  from  diphtheria 
since  1880  are  the  decline  in  the  proportion  to  the  total  population  of  age- 
group  0  to  9  years  and  the  striking  decrease  in  the  susceptibility  of  the  negro 
as  compared  with  the  white.  Similarly,  much  of  the  decrease  in  the  mortality 
from  whooping-cough  since  its  high  level  in  1860-1870  is  associated  with  a 
decline  in  the  proportional  relations  in  the  population  of  this  same  age-group 
and  of  the  negro,  in  whom  the  disease  is  peculiarly  fatal. 

With  pneumonia  the  relation  of  changes  in  the  age-groupings  and  of  the 
proportion  of  negroes  to  whites  in  the  population  to  mortality  is  a  much  more 
complex  question,  because  of  lack  of  knowledge  of  the  relative  frequency  of 
lobar  and  broncho-pneumonia  in  the  past  and  because  both  forms  of  pneumonia 
are  particularly  fatal  in  both  extremes  of  life.  Since  1850,  the  proportions  of 
individuals  in  the  population  in  both  early  life,  when  mortality  is  high,  and 
between  ages  10  and  39,  when  it  is  comparatively  low,  have  declined,  but  that 
above  age  39,  when  mortality  rapidly  increases  to  old  age,  has  risen  markedly. 

TUBERCULOSIS. 

Under  the  title  consumption,  pulmonary  tuberculosis  appeared  in  the  table 
of  interments  in  1812  as  an  important  cause  of  death,  with  252  out  of  a  total 
of  1,184  deaths,  or  21  per  cent  or  over  1  in  5  of  all  deaths,  and  under  one  or 
the  other  of  these  titles  the  disease  can  be  followed  in  each  subsequent  year. 
Under  this  rubric  have  been  included  in  the  present  study  also  deaths  assigned 
to  pulmonary  hemorrhage  and  laryngeal  tuberculosis.  While  it  is  probable 
that,  in  the  early  days,  the  diagnosis  of  lethal  pulmonary  tuberculosis  was 
made  with  a  fair  degree  of  accuracy,  particularly  in  cases  of  ordinary  dura¬ 
tion,  it  is  likely  that  deaths  classified  under  this  rubric  included  some  deaths 
from  chronic  non-tuberculous  pneumonia  and  empyema,  tumors  of  the  lungs 
and  of  the  mediastinal  structures,  and  that  some  deaths,  especially  from  the 
acute  types  of  pulmonary  tuberculosis,  were  classified  under  other  headings. 

Under  the  heading  “  other  forms  of  tuberculosis”  have  been  assembled 
deaths  attributed  in  the  tables  of  interments  to  scrofula,  Potts’s  disease, 
caries  of  the  vertebras,  disease  of  the  hip  and  spine,  white  swelling,  and  tuber¬ 
culous  meningitis,  until  the  adoption  of  the  international  classification  in 
1899  and,  since  that  date,  all  deaths  assigned  to  tuberculosis  of  other  organs 


FEBRILE  DISEASES 


381 


than  the  lungs  and  larynx.  In  the  early  years  a  considerable  number  of  deaths 
were  attributed  to  scrofula.  Of  the  total  of  215  deaths  credited  in  1875  to 
meningitis,  cerebro-spinal  meningitis,  and  tuberculous  meningitis,  83  were 
ascribed  to  the  latter  cause.  It  is  likely  that  until  1899  many  of  the  deaths 
classified  under  dropsy  of  the  head,  hydrocephalus,  convulsions,  and  marasmus 
were  really  due  to  tuberculosis.  There  must  have  been  a  considerable  number 
of  deaths  due  to  generalized  miliary  tuberculosis  and  tuberculous  peritonitis 
classified  under  other  headings.  It  seems  certain,  therefore,  that  throughout 
the  nineteenth  century  the  total  number  of  deaths  due  to  “  other  forms  of 
tuberculosis  ”  was  much  larger  than  the  actual  figures  indicate. 

The  incentive  that  has  come  into  existence  during  the  past  20  or  25  years, 
on  account  of  the  exclusive  clauses  in  insurance  policies  of  a  certain  type,  to 
conceal  deaths  from  tuberculosis  by  reporting  them  under  other  rubrics,  has 
unquestionably  resulted  in  willful  falsification  of  the  returns  to  a  certain 
extent.  Typhoid  fever,  malaria,  chronic  bronchitis,  and  pneumonia  have  been 
the  chief  rubrics  of  classification  of  such  deaths.  As  a  matter  of  fact,  chronic 
bronchitis  since  1899  (table  60)  is  the  only  one  of  these  rubrics  to  which  any 
considerable  number  of  deaths  from  pulmonary  tuberculosis  could  have  been 
credited.  Were  all  the  deaths  from  this  cause  since  1899  assigned  to  pul¬ 
monary  tuberculosis,  which  is  by  no  means  warranted,  the  annual  rates  for 
the  latter  would  be  raised  somewhat,  but  the  general  trend  of  the  curve  of 
mortality  would  not  be  materially  changed.  Counterbalancing  this  source  of 
error,  on  the  other  hand,  are  to  be  taken  into  account  the  consistent  efforts 
put  forth  in  the  health  department  to  obtain  greater  accuracy  in  the  certifica¬ 
tion  and  classification  of  causes  of  death,  and  the  fact  that  newer  methods  of 
diagnosis  and  better  medical  training  have  tended  to  render  the  diagnosis  of 
tuberculosis  more  certain. 

The  establishment  of  sanatoria  in  the  last  14  years  without  the  city  limits 
for  the  reception  of  cases  of  pulmonary  tuberculosis  has  exerted  in  a  very 
direct  way  a  decidedly  favorable  influence  upon  the  official  death-rates  from 
this  affection.  During  the  8  years  1913  to  1920  there  were  in  the  three  larger 
sanatoria  within  the  state  (Sabillasville,  Eudowood,  and  Jewish  Home  for 
Consumptives)  811  deaths  from  pulmonary  tuberculosis  among  patients  sent 
from  Baltimore  City.  These  individuals  would  have  died  within  the  city  and 
their  deaths  would  have  been  recorded  in  the  official  figures  for  the  latter  had 
these  sanatoria  not  been  in  existence.  When  this  number  is  added  to  the 
total  number  of  deaths  from  pulmonary  tuberculosis  recorded  within  the  city 
during  these  8  years,  it  is  evident  that  by  this  change  of  location  for  the  act 
of  death  the  official  figures  for  deaths  from  this  affection  have  been  made  to 
undergo  a  reduction  of  at  least  9  per  cent  [811  -r-  9,764  (i.  e.,  8,953  +  811) 
=  9.06  per  cent].  In  other  words,  by  charging  deaths  of  Baltimore  citizens 
temporarily  domiciled  for  treatment  in  extra-urban  sanatoria  against  the 
counties  in  which  the  latter  are  situated,  instead  of  against  the  city  in  which 
they  became  ill  and  were  registered  as  cases,  a  purely  fictitious  reduction  of 
9  per  cent  in  the  number  of  deaths  from  pulmonary  tuberculosis  in  Baltimore 
has  resulted.  As  all  of  these  811  individuals  were  white,  this  apparent  and 
quite  artificial  decrease  in  the  number  of  deaths  in  this  race  from  pulmonary 
tuberculosis  in  this  period  was  12.5  per  cent  (811  -f-  6,503  =  12.5  per  cent) 
(table  85).  This  practice  has  exerted  a  marked  influence  upon  the  death-rates 


382  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

for  tuberculosis.  These  deaths  thus  transferred  were  not  counterbalanced  by 
deaths  of  tuberculosis  within  the  city  of  non-residents,  which  in  1917,  a 
typical  year,  was  only  23,  a  number  far  less  than  the  probable  number  of 
deaths  of  citizens  of  Baltimore  in  places  other  than  these  3  sanatoria.  Indeed, 
during  the  last  20  years  considerable  numbers  of  individuals  with  tuberculosis 
who  otherwise  would  have  died  in  the  city  have  moved  to  the  nearby  suburban 
districts  on  the  advice  of  physicians. 

The  annual  mortality-rates  for  pulmonary,  other  forms,  and  all  forms  of 
tuberculosis  are  given  in  table  78  and  graph  21.  The  rates  for  pulmonary 
tuberculosis  often  show  rather  wide  fluctuations,  not  only  from  year  to  year, 
but  over  terms  of  years.  Starting  with  the  unusually  high  rate  of  616  in 
1812,  and  falling  below  500  in  only  4  of  the  following  10  years,  the  rates  fell 
from  557  in  1821  to  278  in  1824.  Reacting  the  next  year  to  416,  they  fell 
gradually  to  323  in  1829.  Ascending  to  437  in  1832,  the  rates  had  declined 
to  298  in  1836,  and  after  another  short  upward  turn  to  362  in  1838,  they  fell 
to  297  in  1840.  During  the  next  14  years  the  rates  rose,  except  for  a  slight 
recession  in  1850,  continuously  to  506  in  1854.  From  this  point,  but  with 
some  irregularity,  they  descended  to  326  in  1867.  With  slight  annual  fluctua¬ 
tions  the  rates  again  gradually  rose  to  381  in  1876,  and  then  fell  by  gradual 
steps  to  273  in  1889.  After  a  slight  reaction  to  '292  in  1890,  there  was  a 
gradual  decline  during  the  following  years  to  197  in  1899 :  With  a  gradual 
ascent  to  257  in  1904,  there  was  an  irregular  decline  to  183  in  1915.  Then 
by  even  steps  the  rates  rose  to  206  in  1918,  but  fell  to  143  in  1919  and  to  128  in 
1920.  The  annual  rates  for  other  forms  of  tuberculosis,  while  in  general  low, 
varied  rather  widely  between  1812  and  1874.  In  1812,  1815,  1817,  1818, 
1819,  and  1829,  no  deaths  were  registered  under  the  headings  composing  this 
rubric.  During  the  remaining  years,  the  rates  varied  from  the  lowest,  1,  in 
1826  to  the  highest,  19,  in  1822.  Rates  as  high  as  8,  10,  12,  and  13  occurred 
in  a  few  years.  In  1875,  due  very  largely  to  the  recognition  of  tuberculous 
meningitis  in  the  nosological  classification,  the  rate  jumped  to  60.  From 
this  date  the  rates  declined  gradually,  but  by  irregular  steps,  to  20  in  1898. 
The  rate  rose  abruptly  to  50  in  1899,  and  after  registering  42  in  1900  and 
46  in  1901,  it  fell  to  22  in  1902.  The  rate  ascended  during  the  next  3  years, 
and  in  1905  stood  at  39.  It  gradually  fell  to  28  in  1910.  Reacting  again  to 
39  in  1911,  it  fell  continuously  to  32  in  1917.  Rising  to  36  in  1918,  the  rate 
fell  to  30  in  1919  and  to  23  in  1920.  Since  the  striking  rise  in  the  rate  for  this 
rubric  in  1875,  rates  lower  than  23  were  attained  in  1891,  from  1893  to  1898, 
inclusive,  and  in  1902. 

Before  1875,  for  obvious  reasons,  the  rates  for  all  forms  of  tuberculosis  were 
but  slightly  higher  than  those  for  pulmonary  tuberculosis.  With  the  rise  in  the 
former  and  the  fall  in  the  latter  after  this  date  the  curves  for  the  two  grad¬ 
ually  separate.  From  the  high  level  of  434  in  1876,  the  rate  for  all  forms 
declined  to  259  in  1896,  and  after  reacting  to  285  in  1904,  receded  by  gradual 
steps  to  214  in  1915.  During  the  next  3  years  the  rate  rose  to  242  in  1918, 
and  fell  precipitously  to  173  in  1919  and  to  151  in  1920. 

A  very  clear  idea  of  the  course  of  tuberculosis  in  Baltimore  is  obtained  from 
study  of  death-rates  for  pulmonary,  other  forms,  and  all  forms  of  the  disease 
averaged  for  5-  and  10-year  periods  (table  79,  graphs  22  and  23). 


Table  78. — Number  of  deaths  and  rate  of  death ,  per  100,000  living  inhabitants,  from  all  forms  of 
tuberculosis,  pulmonary  tuberculosis,  and  other  forms  of  tuberculosis,  from  1812  to  1920,  in¬ 
clusive. 


D  =  death.  R  =  rate. 


Year. 

Tuberculosis. 

Year. 

Tuberculosis. 

Year. 

Tuberculosis. 

All 

forms. 

Pul¬ 

monary. 

Other 

forms. 

All 

forms. 

Pul¬ 

monary. 

Other 

forms. 

All 

forms. 

Pul¬ 

monary 

Other 

forms. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1812 

252 

616 

252 

616 

1849 

678 

4  Of] 

A1Q 

in 

fi 

1885 

138° 

369 

1284 

343 

98 

29 

1813 

•  •  •  • 

219 

512 

218 

509 

~ 

~~2 

1850 

589 

359 

581 

354 

8 

o 

5 

1886 

1319 

345 

1202 

315 

117 

31 

1814 

•  •  •  • 

226 

505 

225 

503 

1 

2 

1851 

.... 

690 

409 

679 

403 

11 

7 

1887 

.... 

1224 

314 

1109 

285 

115 

80 

1815 

•  •  •  • 

218 

466 

218 

466 

1852 

.... 

741 

427 

728 

420 

13 

8 

1888 

.... 

1306 

311 

1176 

280 

130 

31 

1816 

•  •  .  • 

254 

520 

250 

512 

4 

8 

1853 

910 

510 

893 

501 

17 

10 

1889 

.... 

1282 

295 

1168 

273 

114 

26 

1817 

•  •  •  • 

239 

469 

239 

469 

1854 

944 

515 

928 

506 

16 

9 

1890 

.... 

1402 

323 

1269 

292 

133 

31 

1818 

•  •  •  • 

306 

575 

306 

675 

1855 

.... 

869 

462 

856 

455 

13 

7 

1891 

.... 

1192 

270 

1096 

248 

96 

22 

1819 

•  •  •  • 

273 

492 

273 

492 

1856 

... 

916 

474 

898 

464 

18 

9 

1892 

.... 

1261 

281 

1146 

255 

115 

26 

1820 

•  •  •  • 

332 

574 

328 

56? 

4 

7 

1857 

.  .  .  „ 

797 

411 

779 

392 

18 

9 

1893 

.... 

1213 

266 

1117 

245 

96 

21 

1821 

•  •  •  • 

341 

565 

336 

557 

5 

8 

1858 

.... 

863 

424 

838 

411 

25 

12 

1894 

.... 

1231 

265 

1127 

243 

104 

22 

1822 

•  •  •  • 

808 

490 

296 

471 

12 

19 

1859 

.... 

728 

348 

723 

346 

5 

2 

1895 

.... 

1247 

265 

1156 

245 

91 

19 

1823 

•  •  •  • 

238 

364 

237 

362 

1 

2 

1860 

.... 

852 

397 

839 

391 

13 

6 

1896 

.... 

1242 

259 

1140 

238 

102 

21 

1824 

•  •  •  • 

191 

281 

189 

278 

2 

3 

1861 

.... 

848 

386 

840 

382 

8 

4 

1897 

.... 

1150 

237 

1061 

218 

89 

18 

1825 

•  •  •  • 

300 

424 

295 

416 

5 

7 

1862 

.... 

759 

337 

747 

331 

12 

5 

1898 

.... 

1252 

254 

1154 

234 

98 

20 

1826 

•  •  •  • 

307 

417 

306 

415 

1 

1 

1863 

.... 

913 

395 

896 

388 

17 

7 

1899 

.... 

1236 

247 

987 

197 

249 

60 

1827 

•  •  •  • 

272 

355 

267 

349 

5 

7 

1S64 

.... 

825 

348 

812 

343 

13 

5 

1900 

... 

1289 

254 

1077 

212 

212 

42 

1828 

•  •  •  • 

298 

375 

295 

371 

3 

4 

1865 

.... 

940 

387 

931 

384 

9 

4 

1901 

1393 

271 

1158 

225 

235 

46 

1829 

•  •  •  • 

267 

323 

267 

323 

1866 

.... 

984 

396 

977 

393 

7 

3 

1902 

.... 

1300 

250 

1188 

228 

112 

22 

1830 

•  •  •  • 

335 

391 

332 

388 

3 

4 

1867 

839 

330 

829 

326 

10 

4 

1903 

.... 

1378 

261 

1216 

231 

162 

31 

1831 

•  •  •  • 

344 

387 

340 

383 

4 

5 

1868 

903 

347 

885 

340 

18 

7 

1904 

■  •  •  • 

1524 

285 

1375 

257 

149 

28 

1832 

•  •  •  • 

408 

443 

403 

437 

5 

5 

1869 

922 

346 

908 

341 

14 

5 

1905 

.... 

1471 

272 

1261 

233 

210 

39 

1833 

•  •  •  • 

397 

416 

394 

413 

3 

3 

1870 

1016 

373 

997 

366 

19 

7 

1906 

.... 

1492 

273 

1317 

241 

175 

32 

1834 

.... 

424 

429 

419 

424 

5 

5 

1871 

940 

337 

922 

331 

18 

6 

1907 

1495 

270 

1317 

238 

178 

32 

1835 

.  .  .  . 

351 

343 

344 

336 

7 

7 

1872 

990 

347 

970 

340 

20 

7 

1908 

.... 

1414 

253 

1250 

223 

164 

29 

1836 

.  ,  .  . 

318 

300 

316 

298 

2 

2 

1873 

1135 

389 

1099 

377 

36 

12 

1909 

1440 

254 

1273 

225 

167 

80 

1837 

.  ,  .  . 

408 

372 

396 

361 

12 

ii 

1874 

.  .  .  . 

1147 

385 

1107 

371 

40 

13 

1910 

1396 

244 

1234 

216 

162 

28 

1838 

•  .  .  . 

421 

371 

410 

362 

11 

10 

1875 

.... 

1243 

408 

1061 

348 

182 

60 

1911 

1388 

240 

1165 

201 

223 

39 

1839 

.  .  .  , 

400 

342 

397 

339 

3 

3 

1876 

.... 

1350 

434 

1186 

381 

164 

53 

1912 

1393 

238 

1189 

204 

204 

35 

1840 

.  .  .  . 

367 

303 

359 

297 

6 

7 

1877 

... 

1285 

404 

1104 

347 

181 

57 

1913 

1341 

227 

1138 

193 

203 

34 

1841 

.  ,  .  . 

456 

365 

450 

360 

6 

5 

1878 

1346 

414 

1150 

354 

196 

60 

1914 

1344 

226 

1145 

192 

199 

33 

1842 

.  .  .  , 

486 

377 

480 

372 

6 

5 

1879 

1328 

400 

1184 

351 

144 

43 

1915 

1290 

214 

1098 

183 

192 

32 

1843 

.  .  .  . 

486 

365 

483 

363 

3 

2 

1880 

•  •  •  • 

1413 

417 

1243 

367 

170 

50 

1916 

1321 

218 

1121 

185 

200 

33 

1844 

.  ,  .  , 

513 

374 

510 

372 

3 

2 

1881 

•  •  •  • 

1384 

400 

1227 

355 

157 

45 

1917 

«  •  •  • 

1407 

230 

1213 

198 

194 

32 

1845 

.... 

530 

375 

525 

371 

5 

4 

1882 

1379 

391 

1235 

350 

144 

41 

1918 

1493 

242 

1273 

206 

220 

£6 

1846 

.  .  .  . 

559 

383 

648 

376 

11 

8 

1883 

.... 

1432 

398 

1300 

361 

132 

37 

1919 

1245 

173 

1029 

143 

216 

30 

1847 

.... 

593 

395 

590 

393 

3 

2 

1884 

1281 

349 

1143 

311 

138 

38 

1920 

1107 

151 

936 

128 

171 

23 

1848 

.... 

629 

407 

621 

401 

8 

5 

Graph  21  (from  table  78).  Annual  crude  mortality  rates  from  all  forms, 
pulmonary,  and  other  forms  of  tuberculosis,  from  1812  to  1920  inclusive. 

(383) 


384  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

Considering  first  the  rates  averaged  for  5-year  periods,  it  will  be  noted 
that  for  all  forms  and  for  pulmonary  tuberculosis,  owing  to  the  relatively 
very  small  contribution  to  the  total  made  by  other  forms  until  1875,  the  two 
curves,  running  a  parallel  course,  closely  approximate  each  other  from  1812 
to  1875.  For  the  next  10  years,  owing  to  a  high  peak  during  this  period  for 
other  forms,  the  curve  for  all  forms  shows  a  correspondingly  sharp  rise, 
while  that  for  pulmonary  tuberculosis  is  almost  smooth.  After  1885,  the 
descent  in  both  curves  is  rapid  and  almost  parallel,  until  1900.  Remaining 
practically  stationary  at  525  between  1812  and  1820,  the  averaged  rate  for 
all  forms  fell  to  425  in  1825  and  to  372  in  1830.  For  the  period  ending  in 
1835  the  rate  rose  to  403,  but  for  the  succeeding  5  years  fell  to  338.  Rising 
steadily  for  the  next  15  years  to  465  between  1851  and  1855,  the  rate  declined 
by  gradual  steps  to  358  between  1866  and  1870.  An  ascent  during  the  next 


Table  79. — Average  rate  of  death,  per  100,000  living  inhabitants,  by  5-  and  10-year 
periods,  from  all  forms  of  tuberculosis,  pulmonary  tuberculosis,  and  other  forms  of 
tuberculosis,  from  1812  to  1920,  inclusive. 


Periods. 

All 

forms. 

Pul¬ 

monary. 

Other 

forms. 

Periods. 

All 

forms. 

Pul¬ 

monary. 

Other 

forms. 

By  5-year 
periods. 

By  10  year 
periods. 

By  5-year 
periods. 

By  10-year 
periods. 

By  5-year 
periods. 

By  10-year 
periods. 

By  5-year 

periods. 

By  10-year 

periods. 

By  5-year 

periods. 

By  10-year 

periods. 

By  5-year 

periods. 

By  10-year 

periods. 

1812-15  . 

525 

524 

1 

1866-70  . 

358 

364 

353 

359 

5 

5 

1816-20  . 

526 

526 

523 

523 

3 

2 

1871-75  . 

373 

•  •  • 

353 

•  •  • 

20 

•  •  • 

1821-25  . 

425 

•  •  • 

417 

•  •  • 

8 

•  •  • 

1876-80  . 

414 

394 

360 

357 

53 

36 

1826-30  . 

372 

399 

369 

393 

3 

5 

1881-85  . 

382 

•  •  • 

344 

•  •  • 

38 

•  •  • 

1831-35  . 

403 

•  •  • 

398 

•  •  • 

5 

•  •  • 

1886-90  . 

318 

350 

289 

317 

30 

34 

1836-40  . 

338 

371 

331 

365 

6 

6 

1891-95  . 

269 

•  •  • 

247 

•  •  • 

22 

•  •  • 

1841-45  . 

371 

•  •  • 

368 

•  •  • 

3 

•  •  • 

1896-1900  . 

250 

260 

220 

234 

30 

26 

1846-50  . 

394 

382 

389 

378 

5 

4 

1901-05  . 

268 

•  •  • 

235 

•  •  • 

33 

•  •  • 

1851-55  . 

465 

•  •  • 

457 

•  •  • 

8 

•  •  • 

1906-10  . 

259 

263 

228 

232 

30 

32 

1856-60  . 

411 

438 

401 

429 

8 

8 

1911-15  . 

229 

•  •  • 

195 

•  •  • 

35 

•  •  • 

1861-65  . 

371 

. . . 

365 

•  •  • 

5 

•  •  . 

1916-20  . 

203 

216 

172 

183 

31 

33 

10  years  culminated  in  an  average  rate  of  414  in  the  5-year  period  ending  in 
1880.  From  this  level  the  averaged  rates  declined  uninterruptedly  to  250  in 
1896-1900.  After  a  slight  reaction  to  268  in  1901-1905,  the  rates  declined 
gradually  to  203  in  1916-1920. 

The  death-rate  for  pulmonary  tuberculosis  was  practically  constant  at  524 
from  1812  to  1820,  when,  by  an  abrupt  descent  in  10  years,  it  fell  33  per 
cent  to  369.  Rising  to  a  rate  of  398  in  1831-1835,  it  descended  by  1840  to 
the  relatively  low  rate  of  331.  From  this  point  there  was  a  wave  covering 
30  years,  with  its  peak  in  1855  with  a  rate  of  457,  and  falling  off  in  1866- 
1870  to  a  rate  of  353,  from  which  it  hardly  deviated  during  the  following  15 
years.  Between  1881  and  1885  there  was  a  minor  drop  in  the  averaged  rate, 
and  between  the  latter  date  and  1900  the  rate  fell  to  220,  to  rise  again  in 
1901-1905  to  235.  In  1906-1910  it  had  fallen  to  228,  and  during  the  last 
10  years  the  fall  was  again  steep,  but  not  so  abrupt  as  between  1885  and 
1900,  to  172. 

After  1885  the  curve  of  the  rates  for  all  forms,  brought  up  by  the  increase 
in  the  rates  for  other  forms  since  1875,  follows  the  same  general  course  of 


FEBRILE  DISEASES 


385 


Graph  22  (from  table  79).  Crude  mortality  rates  from  all  forms,  pul¬ 
monary,  and  other  forms  of  tuberculosis,  averaged  by  5-year  periods,  from 
1812  to  1920,  inclusive. 


Graph  23  (from  table  79).  Crude  mortality  rates  from  all  forms,  pul¬ 
monary,  and  other  forms  of  tuberculosis,  averaged  by  10-year  periods,  from 
1812  to  1920,  inclusive. 


386  PUBLIC  HEALTH  ADMINISTRATION",  ETC.,  IN  BALTIMORE 

that  for  pulmonary  tuberculosis.  Because  the  rate  for  other  forms  contributes 
such  a  relatively  small  quota  to  the  total  rate,  and  since  1900  it  has  stabilized 
around  a  relatively  low  level,  its  effect  upon  the  rate  for  all  forms  is  readily 
absorbed.  During  the  last  20  years  it  has  averaged  about  30. 

Turning  to  the  rates  averaged  for  10-year  periods,  the  curves  are  of  course 
much  smoother.  The  low  point  for  the  first  wave  for  pulmonary  tuberculosis 
is  between  1831  and  1840,  a  drop  to  365  from  a  rate  of  523  in  1812-1820. 
By  1860  the  rate  had  ascended  to  429.  Following  a  fall  between  1861  and 
1870  to  359,  the  averaged  rate  remained  nearly  constant  during  the  next 
decade,  after  which  it  fell  steadily  during  1891-1900  to  234.  Falling  but 
slightly  during  the  next  10  years,  it  dropped  to  183  for  the  decade  1911-1920. 

Viewed  from  any  standpoint,  it  is  very  clear  from  these  sets  of  curves 
that,  on  the  whole,  the  death-rate  for  tuberculosis  in  the  local  population  has 
undergone  a  remarkable  drop  between  1812  and  1920.  The  dotted  lines  on 
graph  21  indicate  the  difference  in  the  course  of  the  curves  made  by  correcting 
the  official  rates  by  the  “  true  rates”  (table  85)  calculated  after  the  addition 
of  the  deaths  from  pulmonary  tuberculosis  at  sanatoria  to  figures  for  the 
deaths  occurring  within  the  city.  From  these  it  is  clear  that  the  descent  in 
the  rates  that  had  occurred  since  1905  is  by  no  means  as  great  as  would  appear 
from  the  uncorrected  figures,  and  that  even  from  the  official  rates  the  angle 
of  fall  in  this  period  is  by  no  means  so  acute  as  those  of  the  decided  falls 
which  began  after  1820  and  1885. 

The  influence  of  race,  as  determined  by  color,  upon  the  death-rates  from 
tuberculosis  has  been  conspicuous.  The  figures  for  the  annual  number  of 
deaths  among  whites  and  negroes  are  available  for  pulmonary  tuberculosis 
since  1875  and  for  other  forms  of  tuberculosis  as  a  group  since  1900  (table 
"80  and  graph  24).  The  rates  for  negroes  under  both  of  these  headings  and  in 


Graph  24  (from  table  80).  Annual  mortality  rates,  specific  for  color  and  sex, 
from  pulmonary  tuberculosis  from  1875  to  1920,  inclusive. 


FEBRILE  DISEASES 


387 


Table  SO. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from 
pulmonary  tuberculosis,  other  forms  of  tuberculosis ,  and  all  forms  of  tuberculosis, 
from  1876  to  1920,  inclusive,  according  to  color  and  sex. 

PULMONARY  TUBERCULOSIS. 

D  =  death.  R  =  rate. 


White. 

Colored. 

tax. 

Year. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1875 

•  • 

1040 

341 

767 

298 

364 

292 

403 

303 

273 

580 

124 

627 

149 

546 

1876 

•  • 

1167 

375 

837 

318 

398 

313 

439 

323 

330 

687 

143 

707 

187 

673 

1877 

•  • 

1094 

344 

771 

287 

358 

275 

413 

297 

323 

659 

126 

608 

197 

696 

1878 

•  • 

1127 

347 

803 

292 

386 

291 

417 

294 

324 

647 

125 

589 

199 

690 

1879 

•  • 

1162 

350 

822 

293 

406 

299 

416 

287 

340 

666 

150 

691 

190 

647 

1880 

•  • 

1221 

361 

878 

306 

416 

300 

462 

312 

343 

658 

154 

693 

189 

632 

1881 

•  • 

1206 

349 

839 

287 

376 

266 

463 

306 

367 

691 

170 

748 

197 

647 

1882 

•  • 

1217 

345 

849 

284 

406 

281 

443 

287 

368 

679 

168 

723 

200 

646 

1883 

•  • 

1272 

353 

881 

289 

411 

279 

470 

299 

391 

707 

171 

719 

220 

698 

1884 

•  • 

1126 

311 

792 

255 

402 

268 

390 

243 

334 

592 

150 

617 

184 

574 

1885 

•  • 

1270 

339 

888 

280 

430 

281 

458 

280 

382 

664 

192 

772 

190 

582 

1886 

•  • 

1204 

315 

843 

261 

416 

266 

427 

256 

361 

616 

144 

567 

217 

654 

1887 

•  • 

1100 

283 

751 

228 

373 

234 

378 

222 

349 

584 

161 

620 

188 

557 

1888 

•  • 

1165 

278 

810 

228 

403 

237 

407 

219 

355 

557 

171 

613 

184 

514 

1889 

•  • 

1147 

269 

827 

228 

412 

238 

415 

220 

320 

493 

145 

510 

175 

481 

1890 

•  • 

1249 

287 

914 

248 

469 

266 

445 

232 

335 

508 

162 

559 

173 

468 

1891 

•  • 

1073 

243 

755 

201 

396 

220 

359 

184 

318 

474 

162 

548 

156 

415 

1892 

•  • 

1127 

251 

780 

205 

388 

212 

392 

198 

347 

508 

173 

575 

174 

455 

1893 

•  • 

1099 

241 

767 

198 

390 

210 

377 

187 

332 

478 

161 

525 

171 

441 

1894 

•  • 

1106 

238 

766 

195 

405 

214 

361 

177 

340 

482 

154 

493 

186 

472 

1895 

•  • 

1141 

242 

794 

199 

386 

201 

408 

197 

347 

483 

190 

597 

157 

392 

1896 

•  • 

1122 

234 

771 

190 

429 

219 

342 

163 

351 

481 

188 

581 

163 

401 

1897 

•  • 

1047 

216 

731 

178 

411 

207 

320 

150 

316 

426 

161 

489 

155 

376 

1898 

•  • 

1061 

215 

731 

175 

385 

191 

346 

160 

330 

438 

179 

534 

151 

361 

1899 

•  • 

987 

197 

666 

157 

365 

178 

301 

138 

321 

419 

166 

487 

155 

365 

1900 

•  • 

1077 

212 

739 

172 

401 

193 

338 

153 

338 

435 

149 

430 

189 

439 

1901 

•  • 

1158 

225 

797 

183 

442 

210 

355 

158 

361 

457 

189 

536 

172 

394 

1902 

#  # 

1188 

228 

807 

183 

456 

213 

351 

155 

381 

475 

202 

563 

179 

404 

1903 

•  • 

1216 

231 

837 

188 

457 

211 

380 

166 

379 

466 

201 

551 

178 

397 

1904 

•  • 

1375 

257 

937 

207 

520 

237 

417 

180 

438 

531 

236 

637 

202 

444 

1905 

•  • 

1261 

233 

833 

182 

471 

212 

362 

154 

428 

511 

229 

609 

199 

432 

1906 

•  • 

1317 

241 

899 

194 

517 

229 

382 

161 

418 

492 

214 

560 

204 

437 

1907 

•  • 

1317 

238 

879 

188 

484 

212 

395 

165 

438 

509 

227 

585 

211 

446 

1908 

•  • 

1250 

223 

833 

176 

498 

216 

335 

139 

417 

478 

220 

558 

197 

411 

1909 

•  • 

1273 

225 

815 

171 

460 

197 

355 

146 

458 

518 

258 

645 

200 

413 

1910 

•  • 

1234 

216 

791 

164 

452 

191 

339 

138 

443 

494 

228 

562 

215 

438 

1911 

•  • 

1165 

201 

733 

150 

437 

183 

296 

119 

432 

475 

235 

570 

197 

397 

1912 

•  • 

1189 

204 

771 

157 

459 

190 

312 

125 

418 

454 

224 

536 

194 

386 

1913 

•  • 

1138 

193 

743 

150 

411 

168 

332 

132 

395 

424 

211 

498 

184 

362 

1914 

•  • 

1145 

192 

745 

149 

467 

189 

278 

109 

400 

424 

215 

500 

185 

360 

1915 

•  • 

1098 

183 

673 

133 

416 

167 

257 

100 

425 

445 

237 

544 

188 

362 

1916 

•  • 

1121 

185 

700 

137 

422 

167 

278 

108 

421 

435 

234 

530 

187 

356 

1917 

•  • 

1213 

198 

730 

142 

453 

178 

277 

107 

483 

494 

281 

628 

202 

380 

1918 

•  • 

1273 

206 

815 

157 

508 

198 

307 

117 

458 

463 

235 

518 

223 

415 

1919 

•  • 

1029 

143 

670 

109 

388 

126 

282 

91 

359 

344 

195 

407 

164 

291 

1920 

•  • 

936 

128 

616 

99 

335 

109 

281 

89 

320 

294 

141 

265 

179 

323 

388  PUBLIC  HEALTH  ADMINISTRATION ,  ETC.,  IN  BALTIMORE 


Table  SO. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from 

pulmonary  tuberculosis,  etc j — Continued. 

ALL  FORMS  TUBERCULOSIS. 


White. 

Colored. 

JL  Oldl* 

Year. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1900 

•  • 

1289 

254 

869 

202 

474 

228 

395 

178 

420 

540 

188 

542 

232 

539 

1901 

•  • 

1393 

271 

945 

217 

519 

246 

426 

190 

448 

567 

236 

669 

212 

485 

1902 

•  • 

1300 

250 

891 

202 

499 

223 

392 

173 

409 

510 

220 

613 

189 

427 

1903 

•  • 

1378 

261 

940 

211 

514 

237 

426 

186 

438 

539 

232 

636 

206 

459 

1904 

•  • 

1524 

285 

1044 

231 

572 

260 

472 

204 

480 

582 

258 

697 

222 

488 

1905 

•  • 

1471 

272 

972 

213 

542 

244 

430 

183 

499 

596 

261 

694 

238 

516 

1906 

•  • 

1492 

273 

1012 

219 

581 

258 

431 

182 

480 

565 

250 

654 

230 

493 

1907 

•  • 

1495 

270 

987 

211 

544 

238 

443 

185 

508 

590 

269 

693 

239 

505 

1908 

•  • 

1414 

253 

951 

201 

564 

244 

387 

160 

463 

530 

244 

619 

219 

457 

1909 

•  • 

1440 

254 

932 

195 

524 

224 

408 

167 

508 

574 

281 

702 

227 

468 

1910 

•  • 

1396 

244 

902 

187 

509 

215 

393 

160 

494 

551 

257 

633 

237 

483 

1911 

•  • 

1388 

240 

874 

179 

518 

217 

356 

143 

514 

566 

280 

680 

234 

471 

1912 

•  • 

1393 

238 

900 

183 

531 

220 

369 

147 

493 

536 

268 

641 

225 

448 

1913 

•  • 

1341 

227 

868 

175 

472 

193 

396 

157 

473 

507 

250 

490 

223 

439 

1914 

•  • 

1344 

226 

854 

170 

530 

215 

324 

127 

490 

519 

265 

617 

225 

438 

1915 

•  • 

1291 

215 

798 

158 

482 

193 

316 

123 

493 

516 

283 

650 

210 

404 

1916 

•  • 

1321 

218 

807 

158 

484 

192 

323 

125 

514 

531 

287 

650 

227 

432 

1917 

•  • 

1407 

230 

858 

167 

522 

205 

336 

129 

549 

561 

317 

709 

232 

437 

1918 

•  • 

1493 

242 

941 

181 

579 

225 

362 

138 

552 

558 

292 

644 

260 

484 

1919 

•  • 

1245 

173 

802 

130 

456 

148 

346 

112 

443 

425 

243 

508 

200 

355 

1920 

•  • 

1107 

151 

715 

114 

388 

126 

327 

103 

392 

360 

181 

340 

211 

380 

OTHER  FORMS  TUBERCULOSIS. 


1900  .. 

212 

42 

130 

30 

73 

35 

57 

26 

82 

105 

39 

112 

43 

100 

1901  .. 

235 

46 

148 

34 

77 

37 

71 

32 

87 

110 

47 

133 

40 

92 

1902  .. 

112 

22 

84 

19 

43 

20 

41 

18 

28 

35 

18 

50 

10 

23 

1903  .. 

162 

31 

103 

23 

57 

26 

46 

20 

59 

73 

31 

85 

28 

62 

1904  .. 

149 

28 

107 

24 

52 

24 

55 

24 

42 

51 

22 

59 

20 

44 

1905  .. 

210 

39 

139 

30 

71 

32 

68 

29 

71 

85 

32 

85 

39 

85 

1906  .. 

175 

32 

113 

24 

64 

28 

49 

21 

62 

73 

36 

94 

26 

56 

1907  .. 

178 

32 

108 

23 

60 

26 

48 

20 

70 

81 

42 

108 

28 

59 

1908  .. 

164 

29 

118 

25 

66 

29 

52 

22 

46 

53 

24 

61 

22 

46 

1909  .. 

167 

30 

117 

24 

64 

27 

53 

22 

50 

57 

23 

57 

27 

56 

1910  .. 

162 

28 

111 

23 

57 

24 

54 

22 

51 

57 

29 

71 

22 

45 

1911  .. 

223 

39 

141 

29 

81 

34 

60 

24 

82 

90 

45 

109 

37 

75 

1912  .. 

204 

35 

129 

26 

72 

30 

57 

23 

75 

81 

44 

105 

31 

62 

1913  .. 

203 

34 

125 

25 

61 

25 

64 

25 

78 

84 

39 

92 

39 

77 

1914  .. 

199 

33 

109 

22 

63 

26 

46 

18 

90 

95 

50 

116 

40 

78 

1915  .. 

193 

32 

125 

25 

66 

26 

59 

23 

68 

71 

46 

106 

22 

42 

1916  .. 

200 

33 

107 

21 

62 

25 

45 

17 

93 

96 

53 

120 

40 

76 

1917  .. 

194 

32 

128 

25 

69 

27 

59 

23 

66 

67 

36 

80 

30 

56 

1918  .. 

220 

36 

126 

24 

71 

28 

55 

21 

94 

95 

57 

126 

37 

69 

1919  .. 

216 

30 

132 

21 

68 

22 

64 

21 

84 

81 

48 

100 

36 

64 

1920  .. 

171 

23 

99 

16 

53 

17 

46 

15 

72 

66 

40 

75 

32 

58 

FEBRILE  DISEASES 


389 


consequence  for  all  forms  of  tuberculosis  are  uniformly  much  higher  than  for 
whites.  For  pulmonary  tuberculosis  during  these  45  years,  there  is  signifi¬ 
cantly  close  correspondence  in  the  general  course  of  the  rates  for  whites, 
negroes,  and  total  population.  The  rate  of  decline  for  whites  is  strikingly 
more  acute  than  for  negroes  between  1875  and  1900.  After  the  break  in  the 
descent  of  the  courses  of  the  rates  for  both  races  due  to  the  sharp  rise  between 
1900  and  1905,  as  shown  by  the  rates  as  averaged  for  5-year  periods  (table 


Table  81. — Average  rate  of  death ,  per  100,000  living  inhabitants,  by  5-year  periods, 
from  all  forms  of  tuberculosis,  pulmonary  tuberculosis,  and  other  forms  of  tubercu¬ 
losis,  according  to  color  and  sex,  from  1876  to  1920,  inclusive. 

PULMONARY  TUBERCULOSIS. 


Periods. 

Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

1876  to 

1880 . 

355 

299 

296 

303 

663 

658 

668 

1881  to 

1885 . 

340 

279 

275 

283 

667 

716 

629 

1886  to 

1890 . 

286 

239 

248 

230 

552 

574 

534 

1891  to 

1895 . 

243 

199 

211 

189 

485 

548 

435 

1896  to 

1900 . 

215 

174 

198 

153 

440 

504 

388 

1901  to 

1905 . 

235 

189 

216 

163 

488 

579 

414 

1906  to 

1910 . 

228 

179 

209 

150 

498 

582 

429 

1911  to 

1915 . 

195 

148 

179 

117 

444 

530 

373 

1916  to 

1920 . 

r  172 

\  193* 

129 

150* 

jl56 

102 

406 

470 

353 

OTHER  FORMS  TUBERCULOSIS. 


1901  to  1905 . 

33 

26 

28 

25 

71 

83 

61 

1906  to  1910 . 

30 

24 

27 

21 

64 

78 

52 

1911  to  1915 . 

35 

25 

28 

23 

84 

106 

67 

1916  to  1920 . 

31 

21 

24 

19 

81 

100 

65 

ALL  FORMS  TUBERCULOSIS. 


1901  to  1905 . 

268 

215 

244 

187 

559 

662 

475 

1906  to  1910 . 

259 

203 

236 

171 

562 

660 

481 

1911  to  1915 . 

229 

173 

207 

140 

529 

615 

440 

1916  to  1920 . 

J  203 

1  224* 

150 

172* 

J-  179 

122 

487 

570 

418 

*  Inclusive  of  5-year  average  of  deaths  from  pulmonary  tuberculosis  in  sanatoria. 


81),  the  curve  for  whites  resumes  its  downward  course  immediately  after 
1905,  and  that  for  negroes  not  until  5  years  later.  The  curves  of  the  rates 
as  averaged  for  10-year  periods  from  1880  to  1920  show  for  the  negro  a  sharp 
rise  between  1900  and  1910,  succeeded  by  a  corresponding  fall  during  the 
final  10-year  period,  while  for  whites  the  curve  continues  to  descend  between 
1900  and  1910,  but  at  an  angle  much  less  acute  than  before,  and  during  the 
final  10-year  period  its  angle  of  fall  is  again  acute.  The  degree  of  decline  in 
the  rates  based  upon  the  official  figures  after  1910  is  sharper  for  whites  than 
for  negroes,  but  this  difference  is  apparent  rather  than  real,  for  it  disappears 


390  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

when  in  the  comparison  the  true  rate  for  whites  (table  85)  is  substituted  for 
the  official  rate.  The  curve  of  the  rate  for  the  total  population  follows  more 
closely  that  for  the  whites  because  of  the  predominantly  greater  numbers  of 
the  latter. 

Coming  now  to  other  forms  of  tuberculosis,  during  the  20  years  for  which 
comparative  figures  exist  the  rates  for  whites  have  fallen  and  those  for 
negroes  risen,  and  the  latter  out  of  all  proportion  to  the  former. 

The  curves  for  whites  and  negroes  for  all  forms  of  tuberculosis  since  1900 
show  a  much  sharper  fall  for  the  former  than  for  the  latter  race,  but  this  dif¬ 
ference  in  the  angle  of  descent  is  much  less  marked  when  the  curve  for  the  true 
rates  for  whites  is  substituted  for  the  curve  of  the  misleading  official  rates. 

The  influence  of  sex  upon  deaths  from  tuberculosis  can  be  determined  for 
both  whites  and  negroes  for  pulmonary  tuberculosis  since  1875  and  for  other 
and  all  forms  since  1900  (tables  80  and  81,  graph  24).  While  the  annual 
rates  for  pulmonary  tuberculosis  for  total  population  and  for  whites  and  for 
negroes  have  fallen  in  45  years  from  341,  298,  and  580  to  128,  99,  and  294, 
respectively,  the  rates  for  the  sexes  have  fallen  as  follows:  white  males  from 
292  to  109;  colored  males  from  627  to  265;  white  females  from  303  to  89; 
and  negro  females  from  546  to  233.  Or,  measured  by  the  decline  in  rates 
averaged  for  5-year  periods  the  total  rate  has  declined  by  52  per  cent  (true 
rate  by  46  per  cent)  ;  the  total  whites  by  57  per  cent  (true  rate  by  50  per 
cent)  ;  male  white  by  47  per  cent;  female  white  by  66  per  cent;  total  negro 
by  39  per  cent;  male  negro  by  29  per  cent;  and  female  negro  by  47  per  cent. 
When  the  curves  for  the  rates  for  pulmonary  tuberculosis  are  plotted  for  race 
and  sex,  it  is  apparent  that,  while  each  follows  in  general  the  same  course  of 
the  curves  for  the  total  population  and  for  whites  and  negroes  separately 
during  this  period,  the  peaks  characterizing  the  period  1901-1910  are  less 
marked  and  the  descent  occurring  after  the  latter  date  is  sharper  in  the 
females  than  in  the  males  of  both  races.  In  the  case  of  each  race  the  averaged 
rates  for  females  were  at  the  beginning  (1880)  about  the  same  as  those  for 
the  males,  and  in  the  case  of  whites  there  was  scarcely  any  difference  before 
1890.  After  1890  for  whites  and  after  1880  for  negroes,  the  rates  for  the  sexes 
deviate  sharply,  and  by  1900  are  widely  separated.  This  in  each  instance  is 
due  to  the  more  rapid  and  steady  fall  in  the  female  rates.  Toward  the  end, 
the  angle  of  fall  is  somewhat  more  acute  for  white  females  and  for  negro 
males  than  for  white  males  and  negro  females. 

For  other  forms  of  tuberculosis  since  1900,  the  rates  for  males  and  females 
of  each  race  follow  the  same  curve,  but  on  the  whole  the  course  for  whites  is 
downward  and  that  for  negroes  is  upward.  In  consequence  of  the  latter  fact, 
and  of  the  fact  that  the  fall  which  occurred  in  the  last  5-year  period  in  the 
rates  for  negroes  of  both  sexes  is  less  abrupt  than  that  for  whites,  the  curves 
for  all  forms  of  tuberculosis  fall  less  acutely  for  negroes  of  each  sex  than  for 
whites  of  each  sex. 

In  table  80  and  in  graph  24  the  course  of  tuberculosis,  pulmonary,  other 
forms,  and  all  forms,  as  previously  described  and  illustrated  for  5-  and  10-year 
averaged  rates,  may  be  followed  for  each  particular  year.  It  will  be  noted 
that  the  upward  and  downward  swings  in  the  rates  plotted  by  years  do  not 
correspond  exactly  with  those  of  the  somewhat  arbitrarily  averaged  rates,  but 
the  correspondence  is  evidently  sufficiently  close  to  warrant  the  use  made  of 


FEBRILE  DISEASES 


391 


the  latter  method  and  to  support,  on  the  whole,  the  conclusions  following 
from  it. 

A  fact  of  considerable  importance  brought  out  by  the  graphic  representation 
of  the  total  rates  by  years  for  pulmonary  tuberculosis,  throughout  the  period, 
and  for  other  forms  and  all  forms  since  1875,  is  that,  while  occasionally  there 
are  abrupt  rises  and  falls  involving  individual  years,  on  the  whole  the  annual 
rates  follow  smooth  courses  over  long  swings  either  up  or  down.  It  will  be 
noted  that  there  were  slight  declines  in  the  mortality  rates  for  pulmonary 
tuberculosis  after  the  influenza  epidemics  of  1814,  1849,  and  1890,  and  a 
marked  decline  during  the  two  years  following  the  severe  one  of  1918.  The 
lowest  rate  ever  attained  for  the  whole  population  previous  to  1912  was  in 

1899,  at  the  end  of  a  long  downward  swing.  After  this  date  the  rate  gradually 
ascended,  and  but  for  the  favorable  influence  exerted  by  the  registration  of 
sanatoria  deaths  out  of  the  city  and  by  the  influenza  epidemic  of  1918,  it  is 
unlikely  that  the  rate  of  1899  would  have  been  notably  bettered,  since  the 
rates  for  both  whites  and  negroes  were  apparently  tending  to  stabilize  after 
1912  at  the  levels  they  had  reached  in  1899.  It  is  of  considerable  interest 
that  a  drop  in  the  rate  for  other  forms  between  1880  and  1898  coincides  very 
closely  with  the  fall  that  was  occurring  in  that  for  pulmonary  tuberculosis. 
The  decline  in  the  death-rates  for  all  forms  of  tuberculosis  for  male  and 
female  of  both  races  following  the  influenza  epidemic  of  1918  is  striking. 
There  were  only  slight  differences  between  the  rates  from  pulmonary  tubercu¬ 
losis  for  males  and  females  of  both  the  white  and  black  races  between  1875 
and  1890-1895. 

According  to  Frick’s  calculations,  the  mortality-rates  for  pulmonary  tuber¬ 
culosis  in  1850  were  317  in  whites  and  468  in  negroes.  Of  the  total  deaths  of 
this  disease  in  both  races,  43.5  per  cent  were  in  males  and  56.5  per  cent  were 
in  females.  There  was  no  difference  for  the  two  sexes  up  to  the  fifteenth  year 
of  age,  but  from  the  fifteenth  to  the  forty-fifth  year  he  found  the  percentage 
of  deaths  was  38  for  males  and  62  for  females.  At  that  date  the  percentages 
of  males  and  females  in  the  population  were  47  and  53,  respectively.  It  is 
clear  that  in  1850  pulmonary  tuberculosis  was  decidedly  more  fatal  for 
females  than  for  males;  25  years  later  the  rates  for  the  two  sexes  were  ap¬ 
proximately  the  same,  and  since  1890-1895  the  rate  in  females  (in  both 
races)  has  gradually  become  much  lower  than  in  males.  In  the  67  years 
between  1850  and  1917  the  rate  for  whites  fell  by  over  50  per  cent  (from  317 
to  142),  and  the  rate  for  negroes  actually  increased  from  468  to  494. 

Data  are  available  for  studying  the  influence  of  age  upon  the  mortality  from 
pulmonary  tuberculosis  upon  the  whole  population  for  the  census  years  1850, 

1900,  1910,  and  1920,  upon  whites  and  negroes  of  both  sexes  for  1910  and 
1920,  and  for  other  forms  of  tuberculosis  for  1910.  Mortality-rates  for 
pulmonary  tuberculosis  in  the  various  age-groups  of  the  whole  population  in 
these  four  census  years  are  compared  in  table  82.  Owing  to  differences  of  the 
age-groupings  of  the  deaths  in  Frick’s  table  for  1850,  the  rates  for  the 
divisions  after  the  sixtieth  year  of  age  can  not  be  compared  with  those  for  the 
other  census  years.  As  the  figures  for  the  total  deaths  as  given  in  the  general 
and  special  tables  vary  somewhat,  and  the  population  figures  of  the  Bureau 
of  the  Census  used  in  these  calculations  differ  slightly  from  those  used 
routinely  elsewhere,  the  rates  for  all  ages  in  the  table  are  not  identical  in  three 


392  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

of  the  years  from  those  of  the  general  table  (table  78)  of  mortality-rates  for  the 
disease.  They  are  344,  239,  and  221,  for  1850,  1900,  and  1910,  instead  of  354, 
212,  and  216,  respectively.  In  both  tables  deaths  occurring  in  extra-urban 
sanatoria  are  excluded. 

In  1850  the  rate  rose  from  76  in  the  first  decade  of  life  to  145  in  the  second, 
524  in  the  third,  and  590  in  the  fourth.  After  receding  to  510  in  the  fifth 
decade,  the  rate  rose  to  716  in  the  sixth,  and  after  the  sixtieth  year  fell  to  583. 
In  this  year,  therefore,  the  chances  of  dying  of  pulmonary  tuberculosis  were 
conspicuously  greatest  in  the  sixth  decade  of  life.  It  is  likely  that  this  dis¬ 
tribution  of  deaths  among  the  age-groups  did  not  change  materially  until 
after  1885.  The  course  of  the  rates  for  the  various  age-groups  was  markedly 
different  in  1900,  after  a  period  of  15  years  in  which  the  mortality-rates  had 
been  steadily  declining.  Though  the  rate  for  the  first  5  years  of  life  was 


Table  82. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from 
pulmonary  tuberculosis,  according  to  age,  for  1850,  1900,  1910,  and  1920. 


D  -  death.  R  =  rate. 


Age-period. 

1850 

1900 

1910 

1920 

D 

R 

D 

R 

D 

R 

D 

R 

Under  1  year . 

5 

82 

32 

295 

6 

59 

2 

13 

Between  1  and  2  years... 

2  to  4  years . 

}17 

92 

f  25 

1  11 

83 

117 

7 

3 

22 

31 

}  16 

29 

5  to  9  years . 

12 

60 

32 

63 

9 

18 

7 

11 

0  to  9  years . 

34 

76 

100 

98 

25 

25 

25 

19 

10  to  19  years . 

53 

145 

118 

120 

104 

101 

76 

61 

20  to  29  years . 

180 

524 

341 

337 

341 

302 

275 

190 

30  to  39  years . 

145 

590 

284 

356 

305 

344 

203 

166 

40  to  49  years . 

74 

510 

175 

301 

224 

327 

158 

171 

50  to  59  years . 

58 

716 

104 

287 

136 

301 

102 

163 

60  years  and  over . 

37 

583 

•  •  •  • 

•  •  •  • 

•  •  •  • 

•  •  •  • 

•  •  •  • 

•  •  •  • 

60  to  69  years . 

•  •  •  • 

•  •  •  • 

64 

309 

75 

302 

72 

200 

70  to  79  years . 

•  •  •  • 

•  •  •  • 

25 

278 

21 

201 

22 

153 

80  years  and  over . 

•  •  •  • 

•  •  •  • 

4 

185 

3 

112 

3 

86 

Total  . 

581 

344 

1215 

239 

1234 

221 

936 

128 

notably  higher  than  in  1850,  there  was  little  difference  in  the  mortality 
between  the  fifth  and  tenth  years  of  age.  Starting  at  the  advanced  level  of  98 
in  the  first  decade  of  life,  the  rate  rose  but  slightly  in  the  second  to  120, 
sharply  in  the  third,  and  attained  356,  its  highest  point,  in  the  fourth.  From 
this  level,  except  for  a  slight  reaction  in  the  seventh  decade,  the  rate  fell  grad¬ 
ually  through  advancing  years.  In  1910,  with  a  considerable  decline  in  mor¬ 
tality  in  all  the  age  divisions  below  the  tenth  year,  the  rate  for  the  first  decade 
was  only  25.  For  the  second,  third,  fourth,  and  seventh  decades  the  rates 
were  not  significantly  lower  than  in  1900.  It  was  in  early  and  in  advanced 
life  that  the  rates  were  lower  than  in  1900.  In  1920,  with  rates  for  each  age- 
group  considerably  lower  than  in  previous  years,  the  highest  rates  occurred 
in  the  third  and  seventh  decades  of  life,  the  rates  being  considerably  less  in 
the  fourth,  fifth,  and  sixth  decades.  As  in  other  years  after  the  completion 
of  the  seventieth  year,  the  chances  of  dying  of  pulmonary  tuberculosis  dimin¬ 
ished  sharply. 


FEBRILE  DISEASES 


393 


It  will  be  noted  that  the  decades  of  highest  mortality  were  the  sixth  in 
1850,  the  fourth  in  1900  and  1910,  and  the  seventh  in  1920.  However,  since 
in  1920  the  rate  for  the  seventh  decade  was  but  slightly  higher  than  in  the 
third,  it  would  appear  that  with  the  decline  in  the  total  rate  one  of  the  chief 
characteristics  has  been  a  relative  decline  in  the  rates  before  and  after  the 
third  decade  of  life.  For  the  white  population,  in  1910,  the  mortality-rate 
(table  83),  comparatively  low  in  the  first  20  years  of  life,  reached  213  in  the 
third  decade.  The  mortality  varied  but  slightly  during  the  next  3  decades,  but 
between  the  sixtieth  and  the  sixty-ninth  years  of  life  advanced  to  287,  its 
highest  level.  After  the  seventieth  year  it  fell  gradually,  but  in  extreme  old 
age  the  mortality-rate  was  still  considerably  higher  than  in  childhood.  In  1920, 
the  mortality-rate  (table  84)  in  the  white  population  followed  a  somewhat  dif¬ 
ferent  course  in  the  various  age-groups.  Instead  of  rising,  it  fell  in  the  fourth 
decade,  and  instead  of  running  a  level  course  during  the  fifth,  sixth,  and  seventh 
decades,  the  rate  gradually  rose  from  the  fortieth  to  the  seventieth  year  of  life. 
The  decline  during  the  remainder  of  life  was  much  less  and  much  more  gradual 
than  in  1910.  These  differences,  so  far  as  the  age-period  between  the  twentieth 
and  fortieth  years  is  concerned,  were  probably  to  some  extent  due  to  the  larger 
proportion  of  deaths  occurring  in  extra-urban  sanatoria  in  1920  as  compared 
with  1910. 

Among  negroes,  in  1910  (table  83),  the  rate  was  significantly  higher  than 
in  whites  in  every  age-group,  but  the  differences  were  conspicuously  greater 
at  the  extremes  of  life.  The  high  level  in  the  earlier  years  of  life,  attained  in 
contrast  to  the  rate  for  whites  in  the  third  instead  of  in  the  fourth  decade, 
was  maintained  during  the  latter  period.  Between  the  fourth  and  the  sixth 
decades  there  was  a  gradual  decline  in  the  rates.  After  falling  considerably 
in  the  seventh,  and  remaining  constant  in  the  eighth  decade,  the  rate  ap¬ 
proached  the  highest  point  in  the  age-period  80  and  over.  In  1920  (table  84), 
with  the  very  considerable  fall  in  the  total  rate  for  all  ages,  as  compared  with 
1910,  there  occurred  a  notable  change  in  the  rates  for  the  different  age-periods, 
except  the  first  and  the  seventh  decades.  As  before,  the  highest  level  was 
reached  in  the  third  decade  of  life,  but  during  the  fourth,  fifth,  and  sixth 
decades  the  rates  descended  steadily  to  a  relatively  very  low  level — from  444 
to  191 — and  then  rising  sharply  in  the  seventh  decade,  fell  precipitously  during 
the  remainder  of  life.  It  will  be  noted  that  in  1920,  when  in  both  races  the 
rates  for  all  ages  had  undergone  a  marked  recession  as  compared  with  1910, 
the  mortality-rates  ran  quite  different  courses  after  the  fortieth  year  of  age. 

The  general  course  of  the  mortality-rates  for  white  males  in  1910  and  1920 
are  in  many  respects  similar.  In  both  years  the  rates  rose  between  the  third 
and  the  seventh  decades  and  fell  during  extreme  old  age.  The  main  dif¬ 
ferences  are  that  in  1910  the  high  level  attained  in  the  fourth  decade  is  main¬ 
tained  during  the  next  two  decades  and  in  the  seventh  decade  there  is  a  sharp 
rise  in  the  rate,  while  in  1920  there  is  an  unbroken  ascent  in  the  rates  between 
the  third  and  the  seventh  decades.  A  significant  difference  is  the  lowered 
rates  in  the  second,  third,  and  fourth  decades  of  life  in  1920  as  compared 
with  1910.  In  comparison  of  the  course  of  the  rates  for  white  females  in  these 
two  years,  there  is  to  be  noted  that  while  high  levels  are  reached  in  the  third 
decade  in  both  years,  in  1910  there  is  but  little  change  during  the  next  three 
decades  of  life,  while  in  1920  the  rates  fall  considerably  during  the  latter 


394 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


Table  83. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from 
pulmonary  tuberculosis,  other  forms  of  tuberculosis,  and  all  forms  of  tuberculosis, 
according  to  age,  color,  and  sex,  for  1910. 

ALL  FORMS  OF  TUBERCULOSIS. 


D  =  death.  R  =  rate. 


Age-period. 

Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

Under  1  year . 

22 

215 

17 

191 

8 

178 

9 

204 

5 

371 

3 

438 

2 

302 

Betw.  1  and  2  years 

14 

146 

10 

118 

6 

137 

4 

98 

4 

355 

1 

180 

3 

526 

2  to  4  years . 

21 

65 

11 

39 

6 

43 

5 

36 

10 

241 

1 

50 

9 

420 

5  to  9  years . 

21 

42 

9 

21 

5 

23 

4 

19 

12 

187 

4 

131 

8 

238 

0  to  9  years . 

78 

77 

47 

53 

25 

56 

22 

50 

31 

238 

9 

143 

22 

327 

10  to  19  years . 

136 

132 

72 

81 

26 

61 

46 

100 

64 

465 

29 

496 

35 

442 

20  to  29  years . 

368 

326 

217 

235 

109 

245 

108 

225 

151 

732 

71 

785 

80 

691 

30  to  39  years . 

327 

368 

211 

289 

123 

346 

88 

235 

116 

734 

69 

902 

47 

576 

40  to  49  years . 

237 

346 

160 

280 

98 

356 

62 

209 

77 

676 

47 

831 

30 

523 

50  to  59  years . 

144 

319 

107 

274 

67 

355 

40 

198 

37 

610 

23 

777 

14 

451 

60  to  69  years . 

80 

323 

68 

310 

50 

506 

18 

150 

12 

416 

7 

530 

5 

379 

70  to  79  years . 

23 

220 

19 

201 

10 

254 

9 

163 

4 

402 

1 

248 

3 

506 

80  years  and  over.. 

3 

112 

1 

42 

1 

117 

•  •  • 

•  •  • 

2 

676 

1 

1075 

1 

493 

Total  . 

1396 

250 

902 

191 

509 

222 

393 

161 

494 

581 

257 

653 

237 

518 

PULMONARY  TUBERCULOSIS. 


Under  1  year . 

6 

59 

4 

45 

1 

22 

3 

68 

2 

148 

1 

146 

1 

151 

Betw.  1  and  2  years 

3 

31 

3 

35 

3 

68 

2  to  4  years . 

7 

22 

2 

7 

1 

7 

1 

7 

5 

120 

•  •  • 

•  •  •  • 

5 

233 

5  to  9  years . 

9 

18 

1 

2 

1 

5 

•  •  • 

•  •  • 

8 

125 

3 

98 

5 

149 

0  to  9  years . 

25 

25 

10 

11 

6 

13 

4 

9 

15 

115 

4 

63 

11 

163 

10  to  19  years . 

104 

101 

54 

61 

18 

42 

36 

78 

50 

363 

20 

342 

30 

379 

20  to  29  years . 

341 

302 

197 

213 

99 

223 

98 

204 

144 

698 

65 

719 

79 

682 

30  to  39  years . 

305 

344 

197 

270 

118 

332 

79 

211 

108 

683 

64 

837 

44 

539 

40  to  49  years . 

224 

327 

152 

266 

92 

334 

60 

202 

72 

632 

44 

778 

28 

488 

50  to  59  years . 

136 

301 

100 

256 

62 

328 

38 

188 

36 

594 

22 

743 

14 

451 

60  to  69  years . 

75 

302 

63 

287 

48 

486 

15 

125 

12 

416 

7 

530 

5 

379 

70  to  79  years . 

21 

201 

17 

180 

8 

203 

9 

163 

4 

402 

1 

248 

3 

506 

80  years  and  over . . 

3 

112 

1 

42 

1 

117 

•  •  • 

•  •  • 

2 

676 

1 

1075 

1 

493 

Total  . 

1234 

221 

791 

167 

452 

198 

339 

139 

443 

521 

228 

579 

215 

470 

OTHER  FORMS  OF  TUBERCULOSIS. 


Under  1  year . 

16 

156 

13 

146 

7 

156 

6 

136 

3 

223 

2 

292 

1 

151 

Betw.  1  and  2  years 

11 

114 

7 

83 

3 

68 

4 

98 

4 

355 

1 

180 

3 

526 

2  to  4  years . 

14 

44 

9 

32 

5 

36 

4 

29 

5 

120 

1 

50 

4 

187 

5  to  9  years . 

12 

24 

8 

19 

4 

18 

4 

19 

4 

62 

1 

33 

3 

89 

0  to  9  years . 

53 

52 

37 

42 

19 

43 

18 

41 

16 

123 

5 

79 

11 

163 

10  to  19  years . 

32 

31 

18 

20 

8 

19 

10 

22 

14 

102 

9 

154 

5 

63 

20  to  29  years . 

27 

24 

20 

22 

10 

22 

10 

21 

7 

34 

6 

66 

1 

9 

30  to  39  years . 

22 

25 

14 

19 

5 

14 

9 

24 

8 

51 

5 

65 

3 

37 

40  to  49  years . 

13 

19 

8 

14 

6 

22 

2 

7 

5 

44 

3 

53 

2 

35 

50  to  59  years . 

8 

18 

7 

18 

5 

26 

2 

10 

1 

16 

1 

34 

•  •  • 

•  •  • 

60  to  69  years . 

5 

20 

5 

23 

2 

20 

3 

25 

70  to  79  years . 

2 

19 

2 

21 

2 

51 

80  years  and  over.. 

Total  . 

162 

29 

111 

23 

57 

25 

54 

22 

51 

60 

29 

74 

22 

48 

FEBRILE  DISEASES 


395 


Table  84. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from 
pulmonary  tuberculosis,  other  forms  of  tuberculosis  and  all  forms  of  tuberculosis, 
according  to  age,  color,  and  sex,  for  1920. 

ALL  FORMS  OF  TUBERCULOSIS. 


D  =  death.  R  =  rate. 


Age-periods. 

Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

Under  1  year . 

24 

162 

11 

85 

5 

76 

6 

95 

13 

661 

9 

940 

4 

396 

1  to  4  years . 

46 

84 

27 

56 

13 

54 

14 

58 

19 

297 

6 

193 

13 

395 

5  to  9  years . 

17 

26 

7 

12 

4 

14 

3 

11 

10 

124 

5 

130 

5 

119 

0  to  9  years . 

87 

65 

45 

38 

22 

37 

23 

40 

42 

255 

20 

252 

22 

258 

10  to  19  years . 

95 

77 

45 

42 

9 

17 

36 

66 

50 

313 

18 

255 

32 

360 

20  to  29  years . 

306 

211 

176 

148 

76 

129 

100 

166 

130 

503 

50 

410 

80 

586 

30  to  39  years . 

222 

181 

141 

140 

80 

159 

61 

122 

81 

371 

42 

3S0 

39 

362 

40  to  49  years . 

174 

188 

122 

159 

76 

199 

46 

119 

52 

334 

35 

422 

17 

233 

50  to  59  years . 

115 

184 

95 

174 

67 

251 

28 

100 

20 

225 

8 

188 

12 

332 

60  to  69  years . 

80 

222 

65 

200 

44 

287 

21 

122 

15 

433 

7 

409 

8 

457 

70  to  79  years . 

25 

173 

23 

176 

12 

214 

11 

147 

2 

147 

1 

165 

1 

133 

80  years  and  over... 

3 

86 

3 

96 

2 

178 

1 

50 

Total  . 

1107 

151 

715 

114 

388 

126 

327 

103 

392 

361 

181 

340 

211 

380 

PULMONARY  TUBERCULOSIS. 


Under  1  year . 

2 

13 

2 

102 

2 

209 

1  to  4  years . 

16 

29 

4 

8 

2 

8 

2 

8 

12 

187 

4 

128 

8 

243 

5  to  9  years . 

7 

11 

4 

7 

3 

11 

1 

4 

3 

37 

1 

26 

2 

48 

0  to  9  years . 

25 

19 

8 

7 

5 

8 

3 

5 

17 

103 

7 

88 

10 

117 

10  to  19  years . 

76 

61 

36 

33 

6 

11 

30 

55 

40 

251 

15 

212 

25 

281 

20  to  29  years . 

275 

190 

161 

135 

68 

116 

93 

154 

114 

441 

44 

361 

70 

513 

30  to  39  years . 

203 

166 

130 

129 

73 

145 

57 

114 

73 

335 

34 

308 

39 

362 

40  to  49  years . 

158 

171 

111 

145 

68 

178 

43 

112 

47 

302 

31 

374 

16 

219 

50  to  59  years . 

102 

163 

87 

159 

61 

229 

26 

93 

15 

191 

5 

118 

10 

277 

60  to  69  years . 

72 

200 

59 

181 

40 

261 

19 

110 

13 

375 

5 

292 

8 

457 

70  to  79  years . 

22 

153 

21 

161 

12 

214 

9 

121 

1 

74 

•  •  • 

•  •  • 

1 

133 

80  years  and  over... 

3 

86 

3 

96 

2 

178 

1 

50 

Total  . 

936 

128 

616 

99 

335 

109 

281 

89 

320 

295 

141 

265 

179 

323 

OTHER  FORMS  OF  TUBERCULOSIS. 


Under  1  year.. . 

22 

148 

11 

85 

5 

76 

6 

95 

11 

559 

7 

731 

4 

396 

1  to  4  years . 

30 

55 

23 

48 

11 

46 

12 

50 

7 

109 

2 

64 

5 

152 

5  to  9  years . 

10 

16 

3 

5 

1 

4 

2 

7 

7 

87 

4 

104 

3 

71 

0  to  9  years . 

62 

46 

37 

32 

17 

29 

20 

34 

25 

152 

13 

164 

12 

141 

10  to  19  years . 

19 

15 

9 

8 

3 

6 

6 

11 

10 

63 

3 

42 

7 

79 

20  to  29  years . 

31 

21 

15 

13 

8 

14 

7 

12 

16 

62 

6 

49 

10 

73 

30  to  39  years . 

19 

16 

11 

11 

7 

14 

4 

8 

8 

37 

8 

72 

•  •  • 

•  •  • 

40  to  49  years . 

16 

17 

11 

14 

8 

21 

3 

8 

5 

32 

4 

48 

1 

14 

50  to  59  years . 

13 

21 

8 

15 

6 

22 

2 

7 

5 

64 

3 

71 

2 

55 

60  to  69  years . 

8 

22 

6 

18 

4 

26 

2 

12 

2 

58 

2 

117 

•  •  • 

•  •  • 

70  to  79  years . 

3 

21 

2 

15 

•  •  • 

•  •  • 

2 

27 

1 

74 

1 

165 

•  •  • 

•  •  • 

80  years  and  over . . . 

Total  . 

171 

23 

99 

16 

53 

17 

46 

15 

72 

66 

40 

75 

32 

58 

26 


396  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

period.  Though  the  rates  were  lower  before  the  thirtieth  and  after  the  sixtieth 
years  of  life  in  1920  than  in  1910,  the  really  significant  differences  lay  between 
the  thirtieth  and  sixtieth  years.  In  negro  males  the  rates  in  1910  ascended  by 
rather  uniform  grades  through  the  first  four  decades  of  life,  and  after  falling 
somewhat  during  the  fifth  and  sixth,  descended  markedly  during  the  seventh 
and  eighth  decades,  to  rise  sharply  in  extreme  old  age  to  the  highest  level 
attained.  In  1920,  although  the  rates  were  considerably  higher  in  the  first 
10  years  of  life  than  in  1910,  thereafter  they  were  much  lower.  Reaching 
a  much  lower  level  in  the  third  decade,  the  rates  fell  somewhat  in  the  fourth, 
rose  in  the  fifth  to  a  point  slightly  higher  than  in  the  third,  and  descended 
sharply  in  the  sixth  decade.  After  a  considerable  reaction  in  the  seventh 
decade,  which,  however,  fell  far  short  of  the  previous  high  levels,  the  rate 
declined  sharply  in  extreme  old  age. 

In  both  1910  and  1920  the  highest  rates  for  the  negroes  were  reached  in 
the  third  decade  of  life.  In  the  former  year  there  was  a  gradual  recession  of 
the  rates  during  the  fourth,  fifth,  sixth,  and  seventh  decades,  followed  by  a 
rise  after  the  seventieth  year.  In  the  latter  year  there  was  a  sharp  decline  in 
the  rate  during  the  fourth  and  fifth,  with  a  corresponding  rise  during  the 
sixth  and  seventh  decades,  and  an  abrupt  fall  after  the  seventieth  year.  It  will 
be  noted  that  in  1920  the  rate  for  all  ages  was  higher  in  female  than  in  male 
negroes,  and  that  this  increase  was  due  to  higher  rates  in  every  decade  of  life 
except  the  fifth.  The  peculiar  shape  of  the  curve  for  the  total  rate  at  all  ages 
for  negroes  in  1920  was  determined  largely  by  age  distribution  of  deaths 
among  the  females.  Speaking  generally,  it  may  be  said  that  the  evidence  at 
hand  indicates  that  in  a  period  of  decline  in  the  total  rates  for  all  ages  in  the 
whole  population,  the  fall  in  the  rates  has  affected  all  age-groups  and  in  much 
the  same  proportion.  It  further  appears  that  the  characteristics  obtaining  in 
1910  for  the  rates  in  the  different  age-groups  in  whites  and  in  negroes  and  in 
males  and  in  females  of  both  races  were  on  the  whole  preserved  in  1920.  The 
inference  seems  justified,  therefore,  that  the  causes,  whatever  they  may  be, 
to  which  the  decline  in  the  rates  have  been  due,  have  acted  with  a  certain 
degree  of  uniformity. 

Mortality  rates  for  other  forms  of  tuberculosis  specific  for  color,  sex,  and 
age  in  1910  are  given  in  table  83.  In  whites  the  high  rates  of  the  early  years 
fell  sharply  after  the  tenth  year  of  life,  while  in  negroes  they  persisted  through 
the  second  decade.  For  the  whole  population  and  among  whites  the  rates 
varied  within  narrow  limits  throughout  life  after  the  tenth  year,  but  the 
rates  for  negroes  were  much  less  stable.  The  negroes’  career  with  these  forms 
of  tuberculosis  is  apparently  closed  with  the  sixtieth  year  of  age,  while  the 
white  is  pursued  through  old  age.  The  rates  for  male  and  female  whites 
followed  much  the  same  course  through  the  earlier  decades  of  life.  The  male 
rate  showed  a  sharp  fall  in  the  fourth  decade,  followed  by  a  rise  lasting  prac¬ 
tically  throughout  the  remainder  of  life.  The  female  rate,  on  the  other  hand, 
rose  during  the  fourth  decade,  fell  sharply  in  the  fifth,  and  ascended  during 
the  sixth  and  seventh.  Among  negroes  the  rate  for  males  rose  to  its  highest 
point  in  the  second  decade  and  fell  in  the  third  to  a  level  which  was  not 
widely  departed  from  until  after  the  fiftieth  year.  In  the  female  the  rate, 
reaching  in  the  first  decade  a  level  double  that  for  males,  conspicuously  fell 
in  the  second  and  third  decades  and  rebounded  to  a  relatively  high  point  in 


FEBRILE  DISEASES 


307 


the  fourth  and  fifth  decades.  In  general,  then,  the  rates  for  the  two  sexes  in 
the  negro  pursued  opposite  courses.  The  peak  of  mortality  occurred  in  the 
male  in  the  second  and  in  the  female  in  the  first  decade  of  life.  The  negro 
male,  less  severely  affected  than  the  female  in  the  first  decade,  repaid  this 
debt  during  the  remainder  of  life.  The  female  paid  her  tribute  in  early  life 
and  in  middle  age.  In  1920,  for  the  whole  population  (table  84),  the  rates 
were  lower  in  each  age-group  below  the  sixtieth  year  than  in  1910.  For  the 
whites,  the  rates  were  lower  in  each  age-group  except  among  females  in  the 
sixth  and  eighth  decades.  Among  negroes,  the  rates  were  uniformly  higher 
in  all  categories  in  the  first  year  of  life ;  for  males  for  every  age-group  except 
1  to  4  years  and  the  second,  third,  and  fifth  decades;  and  for  females  in  the 
age-groups  under  1  year,  5  to  9,  and  in  the  second,  third,  and  sixth  decades. 

When  the  decline  in  the  mortality  of  all  forms  of  tuberculosis  from  1900  to 
1920  is  measured  by  the  percentage  of  decrease  by  10-year  periods  for  each  age- 
group,  as  illustrated  by  graph  25,  it  is  evident  that  the  greatest  decline,  over  55 


A6E  GROUPS 

Graph  25.  Percentages  of  decrease,  occurring  between  1900  and  1920,  in 
rates  of  mortality,  specific  for  the  decades  of  life,  from  all  forms  of  tubercu¬ 
losis  in  the  whole  population. 

per  cent,  has  occurred  in  the  early  ages.  During  the  second  and  third  decades 
of  life,  the  percentages  of  decrease  were  approximately  29  and  25,  respectively. 
An  increase  in  the  rate  of  decline  (32  per  cent)  is  noticeable  during  the  fourth 
decade,  after  which  time  25  per  cent  decrease  obtained  until  during  the  seventh 
decade,  when  it  dropped  to  20.  After  the  seventieth  year,  the  rate  of  decline 
increased  until  in  the  later  years  of  life  the  relative  chance  of  dying  from 
this  disease  was  no  greater  than  during  early  middle  age.  A  straight  line  fitted 
to  this  curve  indicates  that  the  decrease  in  the  death-rate  was  not  only  greatest 
in  the  earlier  years  of  life,  but  gradually  diminished  with  advancing  years. 

The  records  of  the  Bureau  of  Statistics  give  the  reported  cases  of  pulmonary 
tuberculosis  in  the  whole  population,  without  distinction  for  race,  sex,  and  age, 
from  1900  to  1920,  inclusive.  The  morbidity  and  mortality  rates  for  this 
period  are  compared  in  table  85  and  graph  26.  From  this  table  it  is  evident 
that  the  ordinance  of  1894,  requesting  physicians  to  report  cases,  met  with 
but  little  response,  and  that  the  effects  of  the  state  law  of  1906  making 
pulmonary  tuberculosis  a  reportable  disease  were  slight  before  1910.  Before 
the  latter  date  the  bulk  of  the  registered  cases  were  not  reported  directly,  but 


398  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


Table  85. — Number  of  cases ,  reported  and  estimated  and  respective  rates,  per  100,000 
living  inhabitants,  and  number  of  deaths  and  rate  of  death,  per  100,000  living  in¬ 
habitants,  in  the  city  and  extra-urban  sanatoria,  from  pulmonary  tuberculosis,  from 
1900  to  1920,  inclusive. 

C  =  cases.  R  =  rate.  D  =  death.  R  =  rate. 


Year. 

Morbidity. 

Mortality. 

C 

R 

Esti¬ 

mated 

rate. 

City. 

Sanatoria. 

Total. 

D 

R 

D 

R 

D 

R 

1900  . 

274 

54 

318 

1077 

212 

•  •  •  • 

•  •  •  • 

1901  . 

384 

75 

338 

1158 

225 

1902  . 

356 

68 

342 

1188 

228 

1903  . 

551 

104 

346 

1216 

231 

1904  . 

476 

89 

385 

1375 

257 

1905  . 

715 

132 

349 

1261 

233 

1906  . 

733 

134 

361 

1317 

241 

1907  . 

712 

129 

357 

1317 

238 

1908  . 

745 

133 

334 

1250 

223 

1909  . 

919 

162 

337 

1273 

225 

1910  . 

3292 

575 

324 

1234 

216 

1911  . 

1712 

296 

301 

1165 

201 

1912  . 

2248 

385 

306 

1189 

204 

•  •  •  • 

1913  . 

1541 

261 

1138 

193 

72 

14 

1210 

207 

1914  . 

1410 

237 

1145 

192 

83 

17 

1228 

209 

1915  . 

1694 

282 

1098 

183 

66 

13 

1164 

196 

1916  . 

1830 

302 

1121 

185 

111 

22 

1232 

207 

1917  . 

2011 

328 

1213 

198 

125 

24 

1338 

222 

1918  . 

2036 

330 

1273 

206 

138 

27 

1411 

233 

1919  . . 

1867 

259 

1029 

143 

131 

21 

1160 

164 

1920  . 

1407 

192 

936 

128 

85 

14 

1021 

142 

Graph  26  (from  table  85).  Comparison  of  official  and  estimated  crude 
mortality  and  morbidity  rates  from  pulmonary  tuberculosis  in  the  whole 
population  from  1900  to  1920,  inclusive. 


FEBRILE  DISEASES 


399 


were  recorded  through  the  bacteriological  laboratory  as  the  result  of  sputum 
examinations.  It  was  not  until  1909  that  the  rate  of  recorded  morbidity 
approached  the  mortality-rates  and  not  until  1910  the  the  latter  was  exceeded 
by  the  former.  The  sudden  great  increase  in  the  number  of  cases  registered 
in  1910  was  associated  with  the  activity  of  the  newly  established  division 
of  tuberculosis,  as  the  result  of  which  a  considerable  number  of  cases  pre¬ 
viously  known  to  physicians,  dispensaries,  and  charitable  agencies  were  at  this 
time  reported.  Therefore,  the  morbidity-rate  of  this  exceptional  year  was 
never  again  attained.  Owing  to  careful  scrutiny  of  the  death  certificates, 
since  1910  but  few  recognized  cases  of  pulmonary  tuberculosis  have  died  with¬ 
out  having  been  previously  reported  as  clinical  cases.  In  the  4-year  period 
1911-1914,  there  was  a  considerable  drop  in  the  morbidity-rate.  During  the 
four  years  1915-1918  the  rates  rose  continuously,  but  in  1919  and  1920  there 
was  an  abrupt  fall. 

The  mortality-rates,  though  subject  to  annual  fluctuations,  did  not,  except 
for  the  rise  culminating  in  1904,  vary  very  significantly  between  1900  and 
1912,  and  if  the  rates  corrected  for  deaths  in  extra-urban  sanitaria  after  1912 
be  taken  into  account,  they  were  at  about  the  same  level  in  1914  as  in  1900. 
After  a  slight  recession  in  1915,  the  mortality-rates,  like  the  morbidity-rates, 
rose  steadily  until  1918,  and  dropped  as  abruptly  in  the  next  2  years.  In 
explanation  of  these  facts,  it  is  probably  correct  to  assume  that,  on  the  whole, 
between  1910  and  1914,  inclusive,  most  of  the  existing  cases  of  active  pul¬ 
monary  tuberculosis  belonging  to  the  classes  likely  to  be  reported  through 
one  agency  or  another  had  been  recorded.  If  this  be  true,  it  follows  that  the 
rise  in  the  morbidity-rates  between  1914  and  1918  and  in  the  mortality-rates 
between  1915  and  1918,  and  the  subsequent  abrupt  decline  in  both  during 
1919  and  1920,  represent  a  distinct  correlation  between  incidence  and  fatality 
of  this  disease  since  1914.  On  an  average  in  each  year  between  1914  and  1920, 
the  morbidity  exceeded  the  mortality-rate  by  about  one-half. 

In  the  light  of  these  observations,  several  important  inferences  may  be 
drawn.  In  the  first  place,  had  case  reporting  obtained  before  1914  on  the 
same  plane  as  after  this  date,  the  course  of  the  curves  of  morbidity  and  of 
mortality  would  probably  have  shown  the  same  correspondence  during  the 
former  as  they  did  during  the  latter  period,  i.  e.,  the  fallaciously  low  rates 
before  1910  and  the  inordinately  high  rates  between  1910  and  1912  would 
be  replaced  by  morbidity-rates  approximately  one-half  higher  than  the  mor¬ 
tality-rates  between  1900  and  1912.  In  this  case  the  correct  rates  for  the 
period  before  1910  would  not  be  far  from  those  indicated  by  the  estimated 
figures  in  table  85  and  by  the  dotted  line  on  the  graph. 

A  second  inference  of  importance  is  that  within  the  limits  of  the  experience 
of  1914-1920  the  conditions  determining  the  rises  and  falls  in  the  rate  of 
incidence  effected  simultaneously  corresponding  changes  in  the  rate  of  death 
from  pulmonary  tuberculosis.  In  other  words,  the  conditions  which  in  a 
given  time  determine  whether  larger  or  smaller  numbers  of  those  exposed 
shall  develop  into  clinical  cases  are  also  directly  concerned  in  settling  the 
rates  in  respect  of  time  at  which  those  so  affected  shall  die  of  this  disease. 
Whether  the  decline  in  both  morbidity  and  mortality-rates  in  1919  and  1920 
was  due  solely  to  changes  wrought  by  the  influenza  epidemic  of  1918,  or  to 
these  and  to  other  causes  as  well,  it  is  significant  that  both  the  incidence  and 


400  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

the  fatality  of  this  disease,  essentially  chronic  in  the  large  proportion  of 
cases,  at  least,  were  affected  in  almost  equal  degree.  While  the  low  death- 
rate  of  1920  may  have  been  in  large  measure  directly  dependent  upon  the 
lowered  morbidity  of  1919  and  1920,  after  3  years  of  increasing  high  inci¬ 
dence  there  were  ample  clinical  cases  in  reserve  for  a  death-rate  in  1919 
at  least  as  high  as  that  of  1918  had  not  conditions  which  determine  rapid 
decline  to  a  fatal  issue  ceased  to  act  with  their  former  force.  As  the  margin 
between  the  number  of  cases  of  pulmonary  tuberculosis  arriving  annually  in 
the  clinical  state  leading  to  reporting  and  the  number  of  annual  deaths  is 
relatively  small — not  far  from  one-half — and  as  some  of  the  cases  reported 
recover,  it  follows  that  sudden  rises  in  the  death-rate  must  be  first  and 
largely  at  the  expense  of  the  reservoir  of  established  cases. 

The  question  of  the  degree  with  which  the  recorded  morbidity  since  1914 
has  reflected  actual  occurrence  will  be  considered  later. 

For  determining  the  distribution  of  reported  cases  of  pulmonary  tubercu¬ 
losis  by  race  and  sex  over  a  term  of  years,  the  only  available  data  are  the  cases 


Table  86. — Number  of  reported  cases  and  rate  of  morbidity,  per  100,000  living  inhabi¬ 
tants,  of  tuberculosis,  according  to  color  and  sex,  from  1916  to  1920,  inclusive. 


C  =  cases.  It  =  rate. 


Total. 

White. 

Colored. 

Year. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

C 

R 

C 

R 

C 

R 

C 

R 

C 

R 

i 

C 

R 

C 

R 

1916  .. 

1747 

288 

1413 

277 

617 

245 

796 

308 

334 

345 

168 

380 

166 

316 

1917  .. 

1618 

264 

1261 

245 

731 

287 

530 

204 

357 

365 

176 

393 

181 

341 

1918  .. 

1520 

246 

1191 

230 

725 

282 

466 

178 

329 

332 

177 

391 

152 

283 

1919  .. 

1345 

187 

1003 

163 

543 

177 

460 

149 

342 

328 

156 

326 

186 

330 

1920  .. 

1242 

169 

928 

148 

554 

180 

374 

118 

314 

289 

149 

280 

165 

297 

added  to  the  visiting  lists  of  the  nurses  of  the  tuberculosis  division  in  the 
5-year  period  1916-1920.  This  material,  which  is  presented  in  table  86,  reflects 
but  a  rough  approximation  to  actual  occurrence.  The  figures  for  each  year 
represent  the  number  of  cases  out  of  the  total  number  reported,  either  in  the 
same  or  in  some  previous  year,  for  which  consent  for  nursing  supervision  was 
gTanted  by  the  patient  or  by  the  attending  physician.  Thei  discrepancy 
between  these  two  categories  is  perhaps  not  only  variable,  but  often  consider¬ 
able.  Taking  the  material  at  its  face  value,  however,  it  is  notable  that,  on  the 
whole,  the  proportional  distribution  of  cases,  as  indicated  by  morbidity-rates, 
among  whites  and  negroes  and  among  males  and  females  of  the  two  races,  is 
much  the  same  as  that  found  for  deaths.  Striking  exceptions  are,  however, 
the  higher  rates  for  females  than  for  males  among  whites  in  1916  and  among 
negroes  in  1919  and  1920.  The  more  accurate  data  concerning  morbidity  by 
color,  sex,  and  age,  which  exist  in  1921  (rates  calculated  on  the  figures  of  the 
Bureau  of  the  Census  of  the  population  in  1920)  are  given  in  table  87.  The 
proportional  distribution  of  reported  cases  in  this  year  according  to  these 
three  categories  corresponds  in  some  degree  with  that  found  to  obtain  for 


FEBRILE  DISEASES 


401 


deaths  in  1920.  For  the  whole  population,  as  well  as  for  whites  and  for 
negroes,  there  is  the  same  sharp  ascent  of  the  rates  from  early  youth  to  a  peak 
reached  in  the  third  decade  of  life. 

From  this  period  onwards  the  morbidity-rates  decline  much  more  sharply 
than  do  the  mortality-rates.  The  shape  of  the  curves  is  very  similar  for  the 
morbidity-rates  for  the  three  categories.  As  between  males  and  females, 
among  whites,  the  rates  for  the  latter  are  higher  under  the  twentieth  year, 
lower  between  the  twentieth  and  thirtieth  years,  and  after  the  latter  age  show 
a  sharp  decline  which  continues,  but  for  a  slight  reaction  in  the  seventh  decade, 
throughout  the  remainder  of  life.  In  males,  on  the  contrary,  the  high  level 
attained  in  the  third  decade  is  maintained  during  the  fourth  and  fifth  decades. 
After  a  sharp  decline  in  the  sixth  decade,  the  rate  remains  very  much  on  the 


Table  87. — Morbidity,  per  100,000  living  inhabitants,  from  pulmonary  tuberculosis,  ac¬ 
cording  to  age,  color,  and  sex,  for  1921. 


O  =  cases.  R  =  rate. 


Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

O 

R 

C 

R 

O 

R 

C 

R 

C 

R 

C 

R 

C 

R 

Under  1  year . 

9 

61 

5 

39 

4 

61 

1 

16 

4 

203 

2 

209 

2 

198 

1  to  4  years . 

40 

73 

20 

42 

9 

37 

11 

46 

20 

312 

10 

321 

10 

304 

5  to  9  years . 

50 

78 

38 

67 

17 

59 

21 

75 

12 

149 

5 

130 

7 

166 

Under  10  years.... 

99 

74 

63 

54 

30 

51 

33 

57 

36 

219 

17 

214 

19 

223 

10  to  19  years . 

173 

140 

101 

94 

44 

83 

57 

104 

72 

451 

21 

297 

51 

574 

20  to  29  years . 

460 

317 

330 

277 

185 

315 

145 

241 

130 

503 

71 

583 

59 

432 

30  to  39  years . 

299 

244 

231 

230 

143 

284 

88 

176 

68 

312 

41 

371 

27 

251 

40  to  49  years . 

220 

238 

161 

210 

117 

306 

44 

114 

59 

379 

41 

495 

18 

247 

50  to  59  years . 

85 

136 

69 

126 

43 

161 

26 

93 

16 

204 

11 

259 

5 

138 

60  to  69  years . 

44 

122 

41 

126 

22 

144 

19 

110 

3 

87 

2 

331 

1 

57 

70  to  79  years . 

10 

69 

9 

69 

8 

143 

1 

13 

1 

74 

1 

746 

•  •  • 

•  •  • 

SO  years  and  over.. 

Total  . 

1390 

189 

1005 

161 

592 

192 

413 

130 

385 

354 

205 

385 

180 

325 

same  level  to  the  end  of  life.  The  course  of  the  morbidity-  and  mortality-rates 
in  these  two  groups  is  alike  in  that  in  both  the  rates  for  the  female  are  higher 
than  those  for  the  male  in  early  life,  and  that  the  rates  for  female  decline  after 
the  third  decade.  In  the  white  male  the  course  of  both  rates  is  very  similar 
between  the  thirtieth  and  the  fiftieth  years.  In  the  negro  there  is  for  both 
sexes  a  striking  correspondence  in  the  shape  of  the  curves  for  morbidity  and 
mortality  for  the  different  age-groups.  In  summary,  it  is  to  be  observed  in 
the  two  races  that  for  morbidity  as  for  mortality  the  courses  of  the  curves  in 
general  are  strikingly  similar  for  females  and  somewhat  similar  for  males. 
These  correspondences  would  probably  be  even  closer  if  comparison  could  be 
made  for  the  same  year  and  if  the  mortality  data  included  the  deaths  occurring 
in  the  extra-urban  sanatoria. 

The  numerous  factors  which  may  have  affected  directly  or  indirectly  the 
incidence  and  mortality  of  tuberculosis  in  the  109  years  under  review  will  be 
discussed  as  briefly  as  possible  under  population,  eleemosynary  agencies,  gen- 


402  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

era!  sanitation,  specific  measures  of  administrative  control,  and  the  influence 
of  other  diseases. 

Influence  of  population  changes  upon  mortality  from  tuberculosis  may  be 
conceived  to  have  been  exerted  through  rate  of  growth,  changes  in  racial 
composition,  financial  prosperity  and  depression,  and  the  quantity  and  quality 
of  food.  Taking  pulmonary  tuberculosis  as  the  criterion  for  comparison,  and 
the  data  recorded  in  Chapter  VIII  for  details  in  regard  to  population  growth 
and  composition,  it  would  appear  that  mere  growth  in  numbers,  determined 
very  largely  during  most  of  the  nineteenth  century  by  rate  of  immigration, 
was  not  an  important  factor  in  the  decline  in  the  death-rate.  The  very  high 
death-rates  obtaining  in  1812  occurred  in  a  city  of  about  50,000  inhabitants 
after  a  prolonged  period  of  an  exceptionally  high  rate  of  increase,  about  9  per 
cent  per  annum,  over  a  period  of  something  more  than  30  years,  in  the  popula¬ 
tion,  and  the  marked  decline  in  the  rate  between  1812  and  1840  took  place 
during  a  period  of  marked  and  steady  decline  in  the  rate  of  population  in¬ 
crease  (table  9).  On  the  contrary,  the  great  rise  in  the  death-rate  from  pul¬ 
monary  tuberculosis  after  1840  and  the  culmination  in  1855  followed  a  great 
and  sudden  rise  in  the  rate  of  population  growth  due  to  immigration,  between 
1840  and  1850,  and  perhaps  for  several  years  of  the  sixth  decennium. 

Coincidentally  with  the  decided  fall  in  the  rate  between  1855  and  1865, 
and  the  practically  stabilized  death-rate  obtaining  between  1865  and  1880, 
the  rate  of  population  increase  had  returned  to  a  much  lower  level,  main¬ 
tained  for  three  decades  (1850  to  1880)  at  about  25  per  cent  or  2.5  per  cent 
per  annum,  approximately  the  same  rate  of  increase  which  characterized 
the  decade  between  1830  and  1840.  The  marked  and  steady  decline  in  the 
tuberculosis  mortality  which  took  place  between  1880  and  1900  happened 
in  the  face  of  an  accelerated  growth-period  (30.7  per  cent)  in  the  first  decade 
and  in  the  face  of  a  retarded  growth-rate  (17.2  per  cent)  during  the  second 
decade.  On  the  other  hand,  the  distinct  check  in  the  rate  of  decline  of  the 
death-rate,  amounting  to  almost  a  standstill,  that  occurred  between  1900  and 
1910,  was  associated  with  the  very  lowest  rate  of  population  increase  (9.7  per 
cent)  recorded.  Similarly  with  the  rise  in  the  rate  of  population  growth  to 
13.8  per  cent  during  the  last  decade,  1910-1920,  the  pulmonary  tuberculosis 
death-rate  declined  on  the  whole.  It  is  clear  that  excessive  rates  of  popula¬ 
tion  growth  were  definitely  associated  with  high  death-rates,  that  moderate 
rates  of  population  increase  were  accompanied  by  falling  or  stationary  death- 
rates,  and  that  a  very  low  rate  of  population  increase  was  coincident  with  a 
slight  rise  and  then  a  slight  fall  in  the  death-rate,  and,  lastly,  that  a  slight 
increase  of  population  growth  was  followed  by  a  resumption  in  death-rate 
decline.  As  any  increase  in  the  rate  of  population  growth  of  over  1  per  cent 
or  1.4  per  cent  per  annum  in  the  Baltimore  population  is  greater  than  the 
natural  increase  by  excess  of  births  over  deaths,  and  must,  therefore,  be  due 
to  immigration,  it  is  evident  that  there  has  existed  a  very  definite  relation 
between  high  death-rates  from  pulmonary  tuberculosis  and  the  immigration 
rate,  i.  e.,  the  former  have  risen  and  fallen  with  the  tide  of  the  latter.  There¬ 
fore,  it  is  here  of  prime  importance  to  examine  with  some  care  such  pertinent 
characteristics  of  these  immigrants  as  race  stock,  place  of  origin,  previous 
living  and  social  conditions,  and  chances  of  financial  and  social  success  on  and 
after  arrival.  As  these  matters  have  been  dealt  with  in  detail  in  the  chapter 


FEBRILE  DISEASES 


403 


on  population,  it  is  only  necessary  here  to  bring  together  in  condensed  state¬ 
ment  the  essential  facts  there  recorded. 

The  high  pulmonary  tuberculosis  death-rates  of  1812  and  the  years  imme¬ 
diately  succeeding  affected  a  population  of  78  per  cent  white  and  22  per  cent 
negro.  The  whites  were  predominantly  of  British  extraction  and  of  colonial 
descent,  but  with  a  considerable  proportion  of  individuals  of  only  the  first 
and  second  generation  in  this  country.  It  is  certain  that  the  bulk  of  this  ele¬ 
ment  could  not  have  been  city  dwellers  in  either  America  or  in  Britain  for 
more  than  one  generation,  since  but  few  American  cities  from  which  they 
would  have  come  had  long  been  populous,  and  the  trend  here,  as  in  Britain, 
at  that  time  was  from  rural  to  urban,  and  persons  of  this  type  well  established 
in  one  growing  city  would  not  in  large  numbers  migrate  to  another.  This 
element  formed  the  majority  of  the  educated  and  wealthy  citizenhood.  The 
considerable  body  of  persons  of  French  extraction  were  in  the  second  genera¬ 
tion  and  had  become  relatively  prosperous,  and  the  same  conditions  applied 
to  most  of  those  of  German  extraction.  Thus,  whites  of  the  relatively  very 
rich  and  thriving  city,  composed  largely  of  stocks  hardy  and  robust,  drawn 
from  the  country,  could  not  in  any  large  proportion  have  been  inured  to 
city  life.  The  wdiite  population  which  had  for  three  decades  been  increasing  at 
the  rate  of  about  90  per  cent,  during  the  next  three  decades  (1810-1840)  in¬ 
creased  at  a  much  less  rapid  rate — about  30  per  cent  per  decade. 

In  1810  the  negro  population  was  practically  new  to  town  and  city  life,  the 
10,343  then  present  had  increased  by  256  per  cent  between  1790  and  1800,  and 
grew  by  84  per  cent  during  the  following  decade.  In  the  next  three  decades  dur¬ 
ing  which  the  death-rate  from  pulmonary  tuberculosis  fell  so  sharply  (graph 
21),  the  negro  population  increased  at  a  very  much  less  rapid  rate  (42,  29,  and 
12  per  cent,  respectively),  and  between  1830  and  1840  but  relatively  slightly 
from  immigration,  but  in  1840,  out  of  a  population  of  102,000,  they  formed 
20  per  cent.  As  during  all  this  period  their  general  death-rate  had  been  much 
higher  than  the  white,  it  is  probable  that  their  death-rate  from  pulmonary 
tuberculosis  was,  as  it  is  known  to  have  been  in  1850,  correspondingly  higher. 
The  greater  part  of  the  negroes  were  free,  and,  though  many  of  them  were 
probably  relatively  well  to  do,  in  comparison  with  the  whites  they  were  poor 
and  illy  housed  and  inadequately  fed.  Therefore,  during  this  period  of  decline 
of  the  death-rate  from  pulmonary  tuberculosis,  roughly  between  1820  and 
1840,  the  most  susceptible  elements  in  the  population,  the  negroes  and  the 
other  recent  rural  immigrants,  were  gradually  decreasing  numerically  in  im¬ 
portance,  and  the  older,  more  stable  white  population  was  in  the  same  manner 
running  into  more  generations  and  becoming  more  inured  to  urban  life  and 
perhaps  to  tuberculosis.  The  negro  was  undergoing  the  same  process,  but 
with  in  each  case  a  relatively  greater  distance  to  cover. 

The  fifth  decade  of  the  nineteenth  century  marked  a  radical  change  in  both 
the  population  composition  and  in  the  tuberculosis  death-rate.  While  the 
latter  rose  sharply  and  steadily  after  1840  and  reached  a  new  high  peak  15 
years  later,  the  population,  which  had,  since  1830  at  least,  been  receiving, 
besides  migrants  of  British  extraction,  considerable  additions  of  Irish  and 
Germans — probably  both  in  larger  proportions  from  rural  districts — during 
and  immediately  following  the  fifth  decade  was  augmented  by  the  influx  of 
crowds  of  the  latter  two  races,  largely  refugees  from  starvation  or  political 


404  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

oppression  or  both.  In  this  decade  the  white  population  increased  by  73  per 
cent  and  the  negroes  expanded  by  34  per  cent,  and  by  1850  practically  all  the 
negroes  were  free  and  had  to  shift  for  themselves.  Thus  there  was  in  a  com¬ 
paratively  short  time  a  great  growth  in  population,  the  new  elements  of 
which  were  largely  if  not  entirely  destitute. 

The  overcrowding,  the  poverty,  and  the  illness  from  various  diseases,  par¬ 
ticularly  small-pox,  typhus  fever,  measles,  and  intestinal  diseases,  was  exces¬ 
sive.  After  1850,  for  the  next  40  years  the  white  population  increased  at  an 
average  rate  of  2.7  per  cent  a  year — 31  per  cent  in  the  first  and  last  and  23  and 
22  per  cent  during  the  intermediate  decades.  Between  1850  and  1860  the 
negro  population  showed  both  an  actual  and  a  large  relative  decrease.  It 
rebounded  during  the  next  decade  with  a  41  per  cent  increase,  but  its  rate  of 
increase  then  sank  gradually  to  25  per  cent  for  the  decade  1881-1890.  Since 
1890  the  negro,  as  well  as  the  white  population,  has  increased  at  slower  rates. 
The  migration  of  Austrians,  Bohemians,  Poles,  and  Italians,  among  the 
whites,  since  1870,  has  brought  in  not  only  new  races  apparently  more  resis¬ 
tant  to  tuberculosis  than  the  Irish  and  Germans,  but,  by  supplying  great 
additions  to  the  group  of  manual  laborers,  has  probably  seriously  restrained 
immigration  of  negroes.  These  people,  however,  have  come  very  largely  from 
villages  and  rural  districts  and  have  perhaps  retarded  rather  than  accelerated 
any  tendency  to  the  fall  of  the  tuberculosis  death-rate  among  whites.  They 
arrived,  however,  in  a  period  of  prolonged  and  relatively  high  prosperity, 
during  which  living  conditions  and  wages  have  improved.  On  the  other  hand, 
the  German  and  Polish  Jew  populations,  the  former  growing  long  and  slowly 
and  the  latter  rapidly  and  only  since  1884,  representing  a  race  or  at  least 
races — for  the  strictly  Semitic  racial  origin  of  the  Polish  Jew  is  questionable — 
long  inured  to  urban  life  and  intimate  associations  with  the  disease,  have 
probably  exerted  an  influence  even  more  favorable  upon  the  death-rate,  par¬ 
ticularly  during  the  last  30  years. 

It  is  difficult  to  determine  the  influence  of  prosperity  and  depression  in 
business  upon  the  history  of  tuberculosis  in  such  a  composite  and  unwelded 
population.  The  very  high  death-rates  obtaining  in  the  early  years  and  last¬ 
ing  until  1820  occurred  in  the  period  of  trade  depression  which  preceded  and 
followed  the  war  of  1812-1815.  The  considerable  reaction  in  the  rates  which 
took  place  between  1830  and  1835,  after  10  years  of  sharp  decline,  synchro¬ 
nized  in  time  to  some  degree  with  the  financial  depression  connected  with 
the  fight  over  the  national  bank  act.  The  rate  which  had  fallen  during  the 
10  years  previous  to  1865  remained  almost  stationary  during  the  local  finan¬ 
cial  depression  following  the  Civil  War  period.  During  the  period  of  the 
return  of  relative  prosperity  which  set  in  after  1880,  there  began  the  great 
decline  which  lasted  20  years.  However,  in  the  almost  equal  stretch  of  years 
1900  to  1918,  with  unexampled  prosperity,  there  was  practically  no  gain  over 
the  forces  of  mortality. 

Baltimore  markets  have,  except  during  some  years  of  the  Civil  War,  never 
lacked  food  in  abundance  and  variety  for  those  who  could  buy,  so  the  question 
of  food-supply  for  the  general  population  has  been  a  relative  one  of  wages 
and  of  intelligence  in  selection  and  preparation  of  diet.  The  people,  on  the 
whole,  have  throughout  the  period  under  consideration  fared  well  in  com¬ 
parison  with  other  communities,  food  having  been  relatively  cheap  and  well 


FEBRILE  DISEASES 


405 


prepared.  It  is  probable  that  much  less  milk  and  milk  products  have  been 
utilized  than  would  have  been  of  advantage,  but  not  less  and  perhaps  more, 
than  in  other  cities.  The  records  of  the  health  department  indicate  that  per 
capita  consumption  of  milk  has  greatly  increased  during  the  last  30  years. 

It  has  been  pointed  in  other  chapters  that  Baltimore  has  never  lacked  chari¬ 
table  agencies,  such  as  benevolent  associations,  homes  for  the  aged  and 
orphans,  and  dispensaries  and  hospitals,  by  means  of  which  the  needy  have 
been  cared  for  and  the  indigent  sick  treated.  Until  recent  years  cases  of  tuber¬ 
culosis  formed  a  conspicuous  portion  of  the  clientele  of  general  dispensaries 
and  hospitals.  They  always  received  without  stint,  certainly  in  the  dispen¬ 
saries,  the  current  orthodox  medicines  and  general  advice.  General  civic  inter¬ 
est  in  tuberculosis  was  aroused  first,  perhaps,  by  Dr.  Osier.  A  special  commis¬ 
sion  authorized  by  the  legislature  in  1902,  under  the  chairmanship  of  Dr. 
W.  S.  Thayer,  rendered  an  exhaustive  report.  As  a  direct  outcome  of  this,  a 
tuberculosis  exhibition  was  held  in  January  1903.  Under  the  leadership  of 
Drs.  Welch,  Osier,  Thayer,  Jacobs,  Jones,  Fulton,  and  numerous  prominent 
laymen,  the  Maryland  Society  for  the  Prevention  of  Tuberculosis  was  organ¬ 
ized  in  1904.  It  has  been  the  center  of  anti-tuberculosis  propaganda  and  has 
been  largely  instrumental  in  securing  all  subsequent  legislation  on  the  subject. 
The  association  has  been  a  strong  influence  in  securing  the  State  Tuberculosis 
Hospital  (1908),  the  Municipal  Hospital  for  advanced  cases  (1904),  Eudo- 
wood  Sanatorium  (1904),  the  Jewish  Hospital  for  Consumptives,  and  the 
Division  of  Tuberculosis  of  the  city  health  department.  Through  the  influ¬ 
ence  of  Dr.  Osier,  the  Phipps  Tuberculosis  Dispensary  was  established  in  con¬ 
nection  with  the  Johns  Hopkins  Hospital  in  1904. 

It  is  unnecessary  to  review  here  the  history  of  the  attempts  at  nuisance 
control  as  applied  to  paving,  street  cleaning,  sewage  disposal,  water,  food,  and 
the  like,  which  have  been  treated  fully  in  previous  chapters.  Suffice  it  to  recall 
that  the  efforts  in  these  directions  in  most  respects  were  hopelessly  inadequate 
and  could  not  have  exerted  any  favorable  influence  until  very  recent  years. 
Striking  declines  in  the  tuberculosis  death-rate  took  place  under  general  sani¬ 
tary  conditions  of  the  worst  kind.  It  is  possible  that  a  gradual  abandonment 
brought  about  after  1880  of  the  use  of  water  of  wells  and  springs  grossly 
polluted  with  human  excreta  from  cesspools  and  privies,  and  therefore  poten¬ 
tial  carriers  of  tubercle  bacilli,  may  have  exerted  a  favorable  influence  upon 
tuberculosis  death-rates.  The  general  water-supply  could  not  have  been  heavily 
laden  with  human,  but  was  perhaps  well  seeded  with  bovine  tubercle  bacilli. 
Too  little  is  known  of  the  fate  of  B.  tuberculosis  in  polluted  drinking-waters 
to  warrant  stressing  this  point,  particularly  in  a  community  in  which  infec¬ 
tion  would  so  readily  occur  by  other  means. 

The  development  of  small  parks,  never  numerous  except  about  the  city 
springs,  in  the  closely  built  areas,  hardly  began  before  1870,  and  the  large 
parks  were  not  available  at  all  to  the  great  mass  of  the  people  until  the  devel¬ 
opment  of  cable  and  electric  traction  in  the  last  decade  of  the  nineteenth  cen¬ 
tury.  The  same  innovation  was  primarily  responsible  for  the  departure  from 
the  old  custom  of  substituting  wide  streets  and  separate  houses  in  new  develop¬ 
ments,  such  as  the  northern  margins  of  the  city,  for  the  old,  closely  built 
blocks.  However,  the  great  mass  of  the  people  continued  to  dwell  in  the  latter. 
The  housing  and  building  laws  of  recent  years  were  not  retroactive,  and  were 


406  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

passed  after ,  in  certain  parts  of  the  city,  whole  blocks  had  become  almost 
solidly  built  up  with  dwellings,  and  family  on  family  had  been  stacked  in 
what  had  been  previously  single-family  dwellings.  While,  in  the  last  20  years, 
many  dwellings  in  alleys  and  courts  have  been  condemned  or  improved,  it  is 
not  possible  to  determine  with  any  accuracy  whether,  on  the  whole,  the  hous¬ 
ing  conditions  of  the  great  bulk  of  the  population  living  in  closely  built  areas 
was  any  worse  or  any  better  in  regard  to  crowding  and  lack  of  reasonable  sun¬ 
light  and  air,  at  any  particular  date  between  1812  and  1900  during  which 
time  the  death-rates  fell  and  rose  again.  Naturally,  marked  overcrowding 
must  have  always  succeeded  excessively  active  immigration  and  have  lasted  for 
some  years  until  building  operations  caught  up  with  the  demand.  But  in 
periods  of  fairly  steady  migration,  construction  and  demand  have  closely 
coordinated. 

In  this  sense,  excess  in  growth  by  immigration  as  before  1812  and  in  1840- 
1850  may  have  influenced  the  high  rates  obtaining  by  increasing  the  rates 
among  both  migrants  and  indigenes.  However,  government  regulations  and 
laws  can  not  be  shown  to  have  exercised  any  material  influence.  The  inspection 
conducted  by  the  tenement  and  lodging  house  division  of  the  health  department 
since  1912  has  undoubtedly  improved  the  general  cleanliness  of  dwellings  of 
this  type. 

The  improvements  in  the  milk-supply  developed  very  gradually  between 
1894  and  1918,  but  except  for  the  exclusion  of  milch  cattle  from  the  city,  they 
can  not,  until  effective  pasteurization  was  enforced  in  the  latter  year,  be  held 
to  have  exerted  any  marked  influence  upon  massive  dosage  of  B.  tuberculosis 
on  any  considerable  proportion  of  the  population.  The  establishment  of  the 
Walker-Gordon  Milk  Laboratory  and  the  sterilization  in  private  homes  of 
milk  for  babies  and  young  children  doubtless  may  have  exerted  a  favorable 
influence  in  this  respect.  On  the  whole,  the  amount  of  bovine  bacilli  taken  by 
the  population  must  have  been  considerably,  though  very  gradually,  cut  down 
since  1900,  due  to  the  efforts  of  farmers,  dealers,  and  the  health  department. 

Butter  has  probably,  through  the  same  influence,  become  a  less  potent 
vehicle  for  the  transmission  of  bovine  tubercle  bacilli.  Federal  meat  inspec¬ 
tion  may  also  have  to  some  degree  accomplished  the  same  results  in  regard  to 
meats,  but  no  such  claim  can  be  made  for  that  instituted  by  the  health 
department. 

The  great  advances  in  the  diagnosis  and  treatment  of  tuberculosis  of  bones 
and  joints  and  of  the  cervical  lymph-glands  during  the  same  period  can  hardly 
have  been  without  influence  distinctly  favorable,  particularly  upon  the  death- 
rate  for  other  forms  of  tuberculosis. 

The  growth  of  public  and  private  measures  of  prophylaxis  can  hardly  have 
failed  to  exert  a  considerable  influence  by  rendering  less  common  than  form¬ 
erly  opportunities  for  repeated  massive  infection  with  tubercle  bacilli  of  the 
human  type  determining  attacks  of  tuberculosis  running  an  acute  course. 

Administrative  activities  on  the  part  of  the  health  department,  directed 
specifically  to  the  control  of  the  spread  of  tuberculosis  through  measures  affect¬ 
ing  persons  and  their  immediate  surroundings,  began  in  1896  and  have  devel¬ 
oped  leisurely  and  according  to  accepted  canons  but  imperfectly.  The  first 
measure,  tentative  and  feeble,  was  the  passage  of  an  ordinance  directing  the 
commissioner  of  health  to  keep  a  registry  of  cases  of  pulmonary  tuberculosis 


FEBRILE  DISEASES 


407 


and  requesting  physicians  to  report  cases.  The  commissioner  was,  however, 
forbidden  to  assume  sanitary  control  of  tuberculous  persons,  except  on  the 
request  of  attending  physicians,  unless  they  were  residents  of  tenements, 
boarding-houses,  or  hotels.  Sputum  examinations,  free  of  charge,  were  under¬ 
taken  by  the  newly  established  bacteriological  laboratory  the  same  year.  But 
few  cases  were  registered  except  through  the  laboratory,  and  there  was  no 
machinery  provided  for  the  supervision  of  the  class  of  cases  covered  by  the 
ordinance. 

Between  1900  and  1905,  Dr.  C.  Hampson  Jones  made  a  number  of  statistical 
and  topographical  studies  on  pulmonary  tuberculosis  in  Baltimore,  collaborated 
actively  with  the  tuberculosis  commission  authorized  by  the  legislature  in  1902, 
and  contributed  largely  to  the  success  of  a  tuberculosis  exhibition.  It  was  by  a 
legislative  enactment  in  1904  that  the  reporting  of  cases  of  pulmonary  tubercu¬ 
losis  by  physicians  and  heads  of  institutions  was  made  compulsory,  and  the 
health  department  was  required  to  fumigate  the  living  quarters  of  known  cases 
of  pulmonary  tuberculosis  after  removal  on  account  of  death  or  other  reasons, 
and  to  furnish  consumptives  with  sputum-cups,  disinfectants,  and  printed 
instructions  in  regard  to  prophylaxis.  Physicians  who  cooperated  with  the 
health  department  in  the  supervision  of  their  consumptive  patients  were  to 
receive  a  small  fee  from  the  state.  The  law  further  provided  that  on  the  refusal 
or  neglect  of  the  attending  physician  to  cooperate,  the  function  of  oversight 
of  a  consumptive  devolved  upon  the  health  department.  Except  to  inaugurate 
in  1906  fumigation  with  formaldehyde  gas  of  the  living  apartments  of  con¬ 
sumptives  after  death,  the  Baltimore  health  department  did  nothing  to  carry 
out  the  provisions  of  this  law  until  1910.  The  ordinance  of  1905,  forbidding 
expectoration  in  streets  and  other  public  places,  with  the  strong  support  of 
jmblic  opinion,  was  so  effectively  enforced  by  the  police  that  by  1910  the 
spitting  nuisance  was  effectively  controlled. 

Under  the  general  supervision  of  Assistant  Commissioner  Jones,  a  division 
of  tuberculosis  was  established  in  the  health  department  on  January  1,  1910. 
The  simple  organization  consisted  of  14  trained  nurses,  under  the  direction 
of  a  superintendent  of  nurses,  of  experience,  intelligence,  and  force.  For 
administrative  purposes  the  city  was  divided  into  14  districts,  to  each  of  which 
a  nurse  was  assigned.  The  new  division  took  over  at  once  1,617  cases  of 
pulmonary  tuberculosis  from  the  Visiting  Nurses*  Association,  an  ably  man¬ 
aged  organization  which  had  for  6  years,  in  addition  to  its  other  work,  cared 
for  needy  tuberculous  patients.  In  many  respects  this  innovation  signified 
only  that  the  health  department  superseded  a  private  organization  in  the 
nursing  care  of  a  large  number  of  cases  of  pulmonary  tuberculosis.  In  the 
very  important  respect,  however,  that  the  public-health  nurses  were  in  larger 
force  and  acted  under  the  authority  of  the  health  department,  conditions  were 
materially  changed.  In  regard  to  giving  advice  and  instructions  to  ambula¬ 
tory  cases,  nursing  care  to  bedridden  cases,  and  assistance  in  gaining  admission 
to  sanatoria  and  to  the  Municipal  Hospital,  there  were  no  important  changes. 
The  chief  innovations  immediately  introduced  were  the  supervision  of  many 
more  cases,  the  supplying  of  sputum-cups,  paper  napkins,  and  disinfectants, 
the  giving  of  more  specific  advice  in  regard  to  mode  of  life  and  changes  in 
home  surroundings  and  in  vocation,  the  arranging  to  have  all  members  of 
families  of  tuberculosis  patients  submit  to  expert  medical  examination,  the 


408  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


selecting  of  the  most  suitable  cases  for  sanatoria  and  the  Municipal  Hospital 
for  advanced  cases,  and  finally,  the  arranging  for  the  fumigation  of  rooms, 
sterilization  of  infected  clothing  and  bedding,  and  the  insisting  upon  the 
cleaning  and  airing  of  the  dwellings  of  “  open  ”  cases  of  pulmonary  tubercu¬ 
losis.  In  1912,  2  more  nurses  were  added  to  the  division  and  in  1917  the 
number  of  nurses  was  increased  to  20.  Two  dispensaries  were  opened  in  1912 
and  an  additional  one  in  1916.  The  principles  of  action  of  Miss  LaMotte,  the 
first  superintendent  of  nurses,  as  set  forth  in  her  first  two  annual  reports,  were 
simple  and  direct.  As  the  primary  work  of  the  health  department  was  to 
minimize  infection,  it  was  most  important  to  control  advanced  cases.  To  those 
for  whom  hospitalization  could  not  be  had,  frequent  visits  of  instruction  and 
oversight  must  be  made.  Though  a  close  working  relation  was  maintained  with 
charitable  organizations,  to  which  the  needy  were  often  referred  for  relief, 
special  diet  was  never  to  be  requested  for  the  tuberculous  unable  to  buy  it, 
because  of  the  premium  that  would  be  set  upon  their  remaining  at  home.  All 
comfort  and  relief  afforded  to  individuals  was  regarded  as  only  incidental. 

“  Our  function  is  to  try  to  reduce  the  amount  of  tuberculosis  in  the  community,  and 

this  is  best  done  by  concentrating  our  efforts  on  care  of  the  last-stage  case . The 

object  of  the  division  is  to  bring  under  supervision  every  case  of  pulmonary  tuberculosis 
in  the  city.  Many  require  little  beyond  advice,  supplies,  and  general  instructions.  Bed¬ 
ridden  cases  require  nursing  care,  and  it  is  upon  these  and  their  contacts  that  chief 
effort  is  concentrated.” 

In  connection  with  a  request  for  special  tuberculosis  dispensaries  in  1911, 
she  wrote 

“  The  chief,  almost  the  only  value  of  the  dispensary  lies  in  its  being  a 
diagnosis  agency;  treatment  amounts  to  practically  nothing.” 

The  physician  in  charge  of  the  department’s  tuberculosis  dispensaries  has 
acted  on  this  principle.  Cases  found  positive  are  advised  to  go  to  sanatoria, 
and  if  this  can  not  be  accomplished,  the  association  with  the  dispensary  usually 
ceases.  Neither  the  methods  of  procedure  nor  the  ideas  underlying  them  have 
undergone  material  changes  in  10  years. 

A  general  idea  of  the  activities  of  the  division  of  tuberculosis  and  of  the 
sources  of  the  cases  reached  and  of  their  disposal  during  the  11 -year  period 
1910-1920,  may  be  obtained  from  table  88,  which  was  compiled  from  the 
annual  reports  of  the  superintendent  of  nurses.  Owing  to  changes  in  the  forms 
of  these  reports  specific  information  under  some  of  the  headings  is  lacking 
in  the  later  years.  The  figures  in  column  1  represent  the  total  number  of 
persons  recorded  in  the  visiting-list  in  each  calendar  year  as  either  positive 
or  suspicious  cases  of  pulmonary  tuberculosis.  They  do  not  include,  however, 
the  large  number  of  persons  who,  on  account  of  household  association  with  posi¬ 
tive  or  suspicious  cases,  were  taken  by  the  nurses  to  dispensaries  for  medical 
examination.  These  are  included  in  the  group  “  Referred  to  dispensaries.” 
Owing  to  the  uncertain  duration  of  their  stay,  patients  in  sanatoria  have  been 
kept  on  the  visiting-lists  until  death  or  recovery.  In  but  few  years  are  there 
references  to  cases  discharged  for  the  latter  reason.  It  will  be  noted  that  the 
number  of  individuals  annually  on  the  lists  increased  very  gradually  between 
1910  and  1916,  and,  then,  after  remaining  nearly  constant  for  3  years  fell 
considerably  in  1920. 


FEBRILE  DISEASES 


409 


Death  was  invariably  the  chief  cause  for  loss  of  names  from  the  list,  but  the 
annual  losses  due  to  removals  from  the  city  and  to  changes  of  address  were  con¬ 
siderable.  Of  less  and  continuously  decreasing  importance  were  losses  due  to 
the  discharge  of  suspicious  cases  as  non-tuberculous.  This  change  was  largely 
the  result  of  the  growth  in  discrimination  in  the  light  of  experience.  The 
number  of  cases  on  the  list  at  the  end  of  each  calendar  year  (column  6) 
represents  the  difference  between  the  whole  number  listed  (column  1)  and 
the  net  losses  (column  2).  The  figures  in  column  6  indicate  in  a  rough  way 
the  approximate  number  of  individuals  on  the  visting-lists  at  any  time  in  the 
several  years  known  or  thought  to  have  pulmonary  tuberculosis.  This  number 
grew  very  steadily  from  2,416  in  1910  to  4,702  in  1916.  Since  the  latter  date 
the  number  of  persons  constantly  under  supervision  was  not  far  from  5,000. 
During  the  period  in  wdiich  they  were  separately  recorded,  the  proportion  of 
suspicious  to  positive  cases  steadily  declined.  In  columns  9  and  10  are  given 
the  numbers  of  new  and  old  cases  listed  in  each  year.  The  number  of  new 
cases  added  to  the  lists  in  no  year  corresponds  with  the  number  of  cases 
officially  reported  (compare  with  table  85).  These  discrepancies  are  due  to 
the  acts  of  private  physicians  in  withholding  permission  to  visit  entirely  or 
for  a  longer  or  shorter  time  after  reporting  cases.  Similarly,  under  sources 
of  reported  cases,  the  figures  in  column  11  indicate  only  the  numbers  of  cases 
reported  by  physicians  for  which  permission  to  visit  was  granted  in  any  par¬ 
ticular  year. 

It  will  be  noted  that  since  1916,  as  the  division  of  tuberculosis  has  gained 
the  confidence  of  the  physicians,  an  increasingly  large  proportion  of  the 
reported  cases  appear  on  the  visiting  lists.  However,  in  later  years  it  is 
evident  that  less  than  half  of  the  reported  cases  of  pulmonary  tuberculosis 
could  have  been  under  the  care  of  private  physicians.  The  relatively  impor¬ 
tant  part  played  by  the  Phipps  Dispensary,  which  since  1904  has  superseded, 
in  regard  to  pulmonary  tuberculosis,  the  medical  clinic  of  the  Johns  Hopkins 
Hospital,  reflects  in  part  the  reputation  of  the  hospital.  The  tuberculosis 
clinic  of  the  University  of  Maryland  as  a  branch  of  the  medical  clinic  of  the 
University  Hospital,  and  the  three  dispensaries  of  the  health  department  have 
contributed  comparatively  lightly  to  the  whole  number  of  reported  and  listed 
cases.  Under  the  heading  “  other  sources  ”  are  included  the  numerous  gen¬ 
eral  dispensaries  and  various  charitable  organizations.  Under  hospitalization 
the  table  shows  all  the  known,  data  in  regard  to  hospital  care,  both  for 
isolation  and  for  cure,  given  at  public  expense.  Here,  however,  no  account 
is  taken  of  cases  received  in  general  hospitals  for  longer  or  shorter  periods, 
nor  for  the  many  cases,  particularly  among  the  well-to-do,  that  have  gone  to 
distant  resorts.  To  the  Municipal  Hospital  have  been  sent  only  advanced  and 
hopeless  cases  selected  from  among  many  claimants  by  the  nurses  as  particularly 
dangerous  to  their  families.  Relatively  few  who  enter  this  institution  leave 
alive.  It  will  be  noted  that  the  number  of  annual  admissions — about  300 
between  1910  and  1917 — greatly  decreased  in  the  last  3  years.  At  Eudowood 
Sanitorium,  where  30  of  the  70  beds  are  reserved  for  advanced  cases,  the 
admission-rate  has  fallen  off  since  1916.  The  high  level  of  admission  to  the 
Jewish  Hospital  was  reached  in  1914  and  1915;  since  the  latter  year  the 
admission-rate  has  greatly  declined. 


410  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

The  annual  admissions  to  the  State  Sanatorium,  reserved  for  incipient  and 
moderately  advanced  cases,  increased  in  number  almost  uninterruptedly  from 
107  in  1908  to  479  in  1917,  but  since  the  latter  date  there  has  been  even  here 
a  slight  falling  off.  The  highest  point  in  hospitalization  was  reached  in  1915, 
with  321  admissions  to  the  Municipal  Hospital  and  656  to  the  three  sanatoria. 
By  1920  these  figures  had  fallen  to  130  and  566,  respectively.  Under  admis¬ 
sions  to  other  sanatoria  are  included  the  relatively  few  cases  reported  by 
nurses  as  having  gone  to  distant  resorts.  These  belong  to  the  class  for  whom 
permission  to  visit  is  rarely  granted.  Among  the  patients  sent  to  the  three 
extra-urban  sanatoria  between  1913  and  1920,  the  years  for  which  records  of 
deaths  among  them  have  been  kept,  the  fatality-rate  varied  from  10  to  23.5 
per  cent.  In  other  words,  of  the  picked  cases  sent  to  curative  sanatoria,  on  an 
average  over  17  per  cent  died  while  in  these  institutions.  The  proportion 
of  deaths  occurring  among  those  who  returned  to  the  city  is  unknown.  The 
activity  of  the  nursing  force  in  the  various  years,  as  measured  by  the  number 
of  visits  paid,  fumigations  of  dwellings  supervised,  persons  sent  to  dispen¬ 
saries,  and  new  cases  apprehended,  is  indicated  in  columns  25,  26,  27,  and  28 
of  table  88.  It  will  be  observed  that  the  greatest  number  of  visits  paid  in  any 
one  year  was  87,102  in  1917,  when  a  total  of  6,645  persons  were  under  observa¬ 
tion.  The  number  of  fumigations  supervised  varied  with  the  numbers  of 
deaths  and  the  movings  of  recorded  living  cases. 

The  reports  contain  some  data  throwing  light  upon  various  phases  of  the 
tuberculosis  problem  in  Baltimore  and  on  the  value  of  the  efforts  exerted  for 
its  solution.  According  to  Miss  LaMotte’s  analysis  of  the  3,107  positive  and 
suspicious  cases  of  pulmonary  tuberculosis  on  the  visiting-lists  on  December 
31,  1912,  20  per  cent  were  recipients  of  charitable  aid.  She  estimated  that  a 
possible  additional  20  per  cent  were  on  the  verge  of  need  of  such  assistance. 
At  least  50  per  cent  of  the  cases  were  well  beyond  want.  Many  of  these  “  live 
in  excellent  houses  and  are  far  removed  from  the  dire  poverty,  overcrowding, 
and  unsanitary  quarters  usually  considered  to  play  such  a  great  part  in  the 
spread  of  tuberculosis.”  In  608,  or  19  per  cent  of  the  houses,  the  patients 
conducted  some  sort  of  small  industry,  the  chief  types  being  laundries,  222; 
boarding-houses,  104;  sewing,  104;  lodgings,  18;  shoemaking,  21. 

An  analysis  of  the  positive  cases  on  the  visiting-lists  on  December  31,  1915, 
in  regard  to  stage  of  the  disease,  ability  to  work,  and  response  to  instruction 
is  probably  typical  of  other  years.  In  respect  of  stage  of  the  disease,  of  the 
3,606  cases,  there  were  classed  as  incipient  107  (2.9  per  cent),  moderately 
advanced  1,981  (54.9  per  cent),  advanced  752  (20.9  per  cent),  chronic  405 
(11.2  per  cent),  arrested  361  (9.1  per  cent).  Of  the  whole  number  under 
observation,  569  were  hospitalized  and  3,037,  or  more  than  80  per  cent,  were  in 
their  homes.  According  to  physical  capacity,  there  were  able  to  work  full 
time,  1,838;  part-time,  715;  unable  to  work  but  not  confined  to  bed,  391. 
Only  93  were  bedridden.  In  regard  to  amenability  to  instruction  for  the 
protection  of  associates,  the  3,245  active  cases  were  classified  as  adequately 
careful,  548;  moderately  careful,  1,322;  careless,  1,375,  or  in  the  proportion, 
of  17,  41,  and  42  per  cent  respectively. 

In  any  scheme  for  the  prevention  of  tuberculosis  by  control  of  cases  of  the 
disease  it  is  of  capital  importance  that  cases  be  recognized  and  reported  in 
their  early  stages.  The  degree  in  which  this  essential  condition  has  been  met 


FEBRILE  DISEASES 


411 


Table  88. — Administrative  activities  directed  toward  the  control  of  tuberculosis,  from 

1010  to  1920,  inclusive. 


Recorded  cases. 


Cases  reported  by — 


Year. 

Total  number  of  per¬ 
sons  on  list. 

Losses. 

Cases  listed  at  end 
of  year. 

New  cases. 

Old  cases  returned. 

Physicians. 

Phipps  Dispensary. 

University  of  Maryland 

dispensary. 

Health  department  dis¬ 

pensaries. 

Tuberculosis  nurses. 

Other  sources. 

Total. 

By  death. 

By  removal,  etc. 

Non-tuberculous. 

Total. 

Positive. 

Suspicious. 

1 

a 

S 

4 

5 

6 

7 

8 

9 

10 

11 

12 

13 

14 

15 

16 

1910  . 

4251 

1835 

776 

620 

439 

2416 

1967 

449 

2591 

43 

432 

431 

107 

706 

915 

1911  . 

4319 

1547 

814 

484 

249 

2772 

2225 

547 

1816 

87 

349 

391 

83 

•  •  • 

358 

625 

1912  . 

4743 

1636 

856 

611 

169 

3107 

2522 

585 

1892 

79 

382 

418 

58 

27 

251 

756 

1913  . 

4985 

1585 

867 

566 

152 

3400 

2728 

672 

1777 

101 

328 

406 

70 

62 

214 

697 

1914  . 

5192 

1535 

838 

495 

202 

3729 

3181 

548 

1704 

88 

286 

439 

39 

133 

157 

650 

1915  . 

5600 

1359 

853 

447 

59 

4175 

3606 

589 

1759 

112 

421 

404 

61 

97 

113 

663 

1916  . 

6135 

1425 

980 

403 

41 

4702 

9 

9 

1859 

101 

606 

? 

9 

132 

9 

? 

1917  . 

6645 

1764 

1086 

644 

34 

4881 

4275 

606 

1869 

74 

682 

9 

9 

134 

9 

9 

1918  . 

6665 

1672 

1176 

482 

14 

4493 

9 

9 

1767 

17 

765 

214 

20 

64 

64 

340 

1919  . 

6613 

1755 

936 

791 

28 

4858 

9 

9 

1575 

45 

670 

243 

25 

62 

9 

575 

1920  . 

6317 

1596 

872 

703 

21 

4721 

9 

9 

1418 

41 

633 

151 

22 

96 

20 

496 

Hospitalization. 


Nursing  activities. 


Year. 

Municipal  hospital. 

State  sanatorium. 

Eudowood  sanatorium. 

Jewish  Sanatorium. 

Other  sanatoria. 

Patients  admitted  to  state 
sanatorium,  Eudowood,  and 
Jewish  Sanatorium. 

Number  of  deaths. 

Percentage,  case  fatality. 

Referred  to  dispensaries. 

Total  number  of  visits  by 
nurses. 

Houses  fumigated  after  death 
of  patients. 

Houses  fumigated  after  re¬ 
moval  of  patients. 

17 

18 

19 

20 

21 

22 

2® 

24 

25 

26 

27 

28 

1910  . 

339 

107 

79 

25 

211 

2903 

1162 

1742 

1911  . 

291 

109 

109 

33 

•  •  •  • 

251 

•  «  •  • 

•  •  •  • 

1917 

61195 

1186 

2011 

1912  . 

310 

180 

123 

53 

•  •  •  • 

356 

•  •  •  • 

•  •  •  • 

3082 

72058 

1157 

1769 

1913  . 

298 

295 

116 

61 

•  •  •  • 

472 

72 

15.3 

3375 

79743 

1107 

2186 

1914  . 

286 

365 

105 

94 

1 

564 

83 

14.7 

2785 

82726 

1110 

2264 

1915  . 

321 

464 

98 

94 

14 

656 

66 

10.1 

2618 

75773 

1042 

2388 

1916  . 

286 

443 

105 

60 

13 

608 

111 

18.3 

2141 

83907 

1288 

2250 

1917  . 

308 

479 

83 

68 

14 

630 

125 

19.8 

3012 

87102 

1100 

1903 

1918  . 

175 

438 

96 

53 

9 

587 

138 

23.5 

1637 

82528 

4457 

1919  . 

160 

475 

78 

63 

5 

616 

131 

21.4 

1796 

76505 

1897 

1920  . 

130 

422 

92 

52 

30 

566 

85 

15.0 

999 

71848 

1649 

1 

27 


412  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


will  be  indicated  by  determining  among  reported  cases  the  interval  of  time 
elapsing  between  the  dates  of  reporting  and  death.  According  to  an  analysis 
by  Miss  LaMotte,  in  1912,  of  the  1,189  deaths  from  pulmonary  tuberculosis 
in  the  city,  856  were  among  cases  on  the  visiting-lists.  Among  these  856, 


deaths  occurred  within — 

1  month  after  reporting .  188  or  22  per  cent. 

First  and  second  month  after  reporting .  115  or  13.4  per  cent. 

Second  and  third  month  after  reporting .  68  or  8  per  cent. 

Third  and  fourth  month  after  reporting .  73  or  8.5  per  cent. 

Within  4  months  after  reporting .  444  or  51  per  cent. 

Within  1  year  after  reporting .  635  or  77  per  cent. 

Within  first  and  second  year  after  reporting .  114  or  13  per  cent. 

Within  second  and  third  year  after  reporting .  87  or  10  per  cent. 


These  figures  were  thought  to  support  the  claim  of  the  nurses  that  report¬ 
ing  was  not  only  delayed,  but  very  incomplete. 

At  the  instance  of  the  writer,  in  1916,  the  deaths  from  pulmonary  tuber- 
losis  which  occurred  during  that  year  among  cases  upon  the  visiting-lists  were 
analyzed  according  to  the  time  which  elapsed  since  they  were  reported.  The 
results  are  presented  in  tables  89  and  90.  The  980  cases  analyzed  included  the 


Table  89. — Distribution  of  deaths  in  1916  from  pulmonary  tuberculosis,  according  to 

years  in  which  the  decedents  were  reported  as  cases. 


Years. 

Total. 

White. 

Colored. 

No.  of  cases 
dying. 

Per  cent  of 
total. 

No.  of  cases 
dying. 

Per  cent  of 
total. 

No.  of  cases 
dying. 

Per  cent  of 
total. 

1910  . 

35 

3.6 

31 

4.6 

4 

1.3 

1911  . 

13 

1.3 

9 

1.3 

4 

1.3 

1912  . 

31 

3.1 

29 

4.3 

2 

0.7 

1913  . 

50 

5.0 

44 

6.6 

6 

1.9 

1914  . 

70 

7.1 

56 

8.4 

14 

4.5 

1915  . 

282 

28.8 

208 

31.0 

74 

24.0 

1916  . 

498 

50.8 

293 

43.7 

205 

66.3 

Total  . 

980 

100 

671 

100 

309 

100 

Table  90. — Time  elapsing  between  data  of  report  and  date  of  death  of  cases  of  pulmonary 

tuberculosis  reported  and  dying  during  1916. 


Time. 

Total. 

White. 

Colored. 

No.  of  cases 
dying. 

Per  cent  of 
total. 

No.  of  cases 
dying. 

Per  cent  of 
total. 

No.  of  cases 
dying. 

Per  cent  of 
total. 

Under  1  week . 

73 

14.8 

43 

14.7 

30 

14.9 

Between  1  and  2  weeks 

59 

11.9 

34 

11.6 

25 

12.4 

Between  2  and  4  weeks 

91 

18.4 

47 

16.0 

44 

21.8 

1  to  2  months . 

94 

19.0 

48 

16.4 

46 

22.8 

2  to  3  months . 

57 

11.5 

29 

9.9 

28 

13.9 

Under  3  months . 

374 

75.6 

201 

68.6 

173 

85.8 

3  to  4  months . 

43 

8.7 

32 

10.9 

11 

5.5 

4  to  6  months . 

46 

9.3 

33 

11.3 

13 

6.4 

Under  6  months . 

463 

93.6 

266 

90.8 

197 

97.7 

6  to  9  months . 

28 

5.7 

23 

7.9 

5 

2.5 

9  to  12  months . 

4 

0.8 

4 

1.4 

Total  . 

495 

100 

293 

100 

202 

100 

FEBRILE  DISEASES 


413 


deaths  occurring  among  listed  cases  at  the  three  extra-urban  sanatoria.  It 
will  be  observed  (table  89)  that  50.8  per  cent  of  the  deaths  were  among  cases 
reported  during  1916  and  28.8  per  cent  among  cases  reported  in  1915,  leaving 
slightly  over  20  per  cent  reported  as  cases  during  the  remaining  5  years  from 
1910  to  1914,  inclusive.  Among  this  latter  group,  the  proportions  which  had 
been  reported  in  each  particular  year  steadily  diminished  from  1914  to  1911. 
As  between  whites  and  negroes,  the  proportions  as  expressed  in  percentages 
were  43.7  and  66.3  for  1916,  and  31  and  24,  respectively,  for  1915.  It  is  note¬ 
worthy  that  of  individuals  dying  in  1916,  a  very  much  larger  percentage 
among  whites  than  among  negroes  had  been  reported  as  cases  in  previous  years. 

Considering  now  the  495  deaths  that  occurred  among  cases  reported  during 
1916  (table  90),  it  is  found  that  in  a  large  proportion  of  instances  death  took 
place  within  a  few  weeks  after  reporting.  In  over  75  per  cent  the  cases  had 
been  reported  only  3  months,  and  in  93.6  per  cent  only  6  months  before  death. 
The  period  elapsing  between  reporting  and  death  was  uniformly  shorter  for 
negroes  than  for  whites.  The  number  of  deaths  between  the  sixth  and  the 
twelfth  month  after  reporting  was  insignificant.  Considered  alone,  the  data 
in.  table  90  suggest  very  strongly  that  case  reporting  was,  as  claimed  by  the 
nurses,  in  many  instances  willfully  delayed,  with  the  result  that  many  cases 
of  pulmonary  tuberculosis  were  brought  under  observation  and  instruction 
much  later  than  the  law  contemplated.  In  support  of  this  point  there  are  two 
main  arguments :  First,  that  there  is  strong  circumstantial  evidence  that  some 
physicians  have  in  certain  instances  delayed  case  reporting  until  it  was  evi¬ 
dent  that  a  fatal  issue  must  soon  ensue  and  further  concealment  would  expose 
them  to  prosecution  when  a  certificate  for  death  of  an  unreported  case  of 
pulmonary  tuberculosis  was  presented;  second,  that  both  in  general  and  in 
comparison  with  certain  other  cities  (New  York  and  Manchester,  for  instance) 
the  morbidity-rates  as  compared  with  the  mortality-rates  are  relatively  low. 
In  reply  to  these  it  is  to  be  said,  that  such  instances  of  willfully  delayed 
reporting  are  relatively  rare;  the  majority  of  all  cases  are  not  reported  by 
physicians,  but  by  dispensaries  and  other  charitable  agencies  where  the  motive 
for  concealment  is  lacking;  the  proportion  of  early  deaths  after  reporting  is 
higher  in  negroes,  among  whom  the  great  mass  of  cases  are  reported  by  such 
agencies  and  not  by  private  physicians;  since  1916,  at  least,  physicians  have 
withheld  consent  to  visit  in  but  a  small  proportion  of  cases  reported  by  them ; 
and  for  over  5  years  the  city  had  been  dragnetted  for  cases  of  tuberculosis 
by  the  health  department  nurses  and  by  charitable  agencies  and  but  a  very 
small  proportion  of  the  large  number  of  contacts  with  known  cases  submitted 
to  medical  examination  were  proved  to  be  clinical  cases  of  tuberculosis. 

In  the  light  of  these  considerations  more  adequate  explanation  must  be 
sought.  Since  it  is  clear  that  the  phenomenon  under  discussion  can  not,  in 
the  nature  of  the  case,  in  any  considerable  measure  be  due  to  willfully 
delayed  reporting,  its  true  explanation  must  be  sought  in  the  natural  history 
of  the  disease  and  the  reaction  of  its  victims.  In  the  discussion  of  the  morbidity- 
curve  two  significant  points  pertinent  in  this  connection  were  established, 
namely,  that,  since  1910,  recognized  cases  must  have  been  reported  with  a 
fair  degree  of  completeness  and  morbidity-  and  mortality-rates  have  had  such 
a  constant  ratio  to  each  other  that  their  simultaneous  rise  and  fall  must  be 
due  to  the  operation  of  the  same  cause  or  causes.  It  appears  from  tables  89  and 


414  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

90  that  the  time  elapsing  between  case  reporting  and  death  is  conspicuously 
shorter  for  negroes  than  for  whites,  and  it  is  well  established  that  the  morbidity- 
and  mortality-rates  were  higher  and  the  disease  on  the  whole  runs  a  shorter 
course  in  the  former  than  in  the  latter.  It  was  found  that  on  a  particular 
day  in  1915  the  “  advanced-stage  ”  group  constituted  21  per  cent  of  the  whole 
number  of  listed  positive  cases.  It  may  be  safely  assumed  that  on  an  average 
from  18  to  25  per  cent  of  all  registered  cases  fall  in  this  category,  and  it  is 
evident  that  it  is  from  this  group  that  the  bulk  of  the  fatal  cases  must  come. 
The  group  “  advanced-stage  ”  reported  cases  can  originate  in  only  two  ways, 
either  by  decline  from  the  stage  next  above,  the  “  moderately  advanced  stage,” 
or  by  entering  the  lists  as  “  advanced-stage  ”  cases  at  the  time  of  reporting. 
The  movement  of  moderately  advanced  cases  is  slow,  and  cases  of  this  group 
remain  stationary,  become  arrested,  become  chronic,  or  go  into  the  “  advanced 
stage.”  Those  that  pursue  the  latter  course  are  the  less  resistant  and  probably 
usually  change  from  the  higher  to  the  lower  stage  shortly  after  being  re¬ 
ported.  The  numbers  of  the  “  advanced-stage 99  group  reported  in  this  stage  of 
the  disease  may  represent  either  cases  of  phthisis  florida,  or  the  not  small  class 
of  persons  with  pulmonary  tuberculosis  in  moderately  advanced  stages  without 
clinical  symptoms  definite  enough  to  cause  them  to  seek  medical  advice  until 
after  a  sudden  decline  in  health,  when  the  disease  has  rapidly  reached  the 
advanced  stage. 

When  the  question  is  considered  in  the  light  of  the  ascertained  facts  and 
the  inferences  that  flow  from  them,  it  becomes  evident  that  in  the  nature  of 
the  case,  in  a  large  proportion  of  instances  of  fatal  pulmonary  tuberculosis 
death  should  occur  within  a  comparatively  short  period  after  case  reporting. 
Here  is  brought  into  prominence  a  fundamental  fact  only  too  frequently 
ignored  by  the  untrained,  namely,  that  there  is  often  a  vast  difference  between 
the  date  of  real  incidence  and  the  date  at  which  a  case  of  phthisis  is  likely 
to  attain  the  stage  of  reporting.  On  the  whole,  it  seems  probable  that  in  the 
period  under  review  a  very  considerable  proportion  of  those  who  developed 
active  pulmonary  tuberculosis  have  not,  for  one  reason  or  another,  exposed 
themselves  to  the  conditions  that  lead  to  diagnosis  and  reporting  until  the 
disease  is  well  advanced,  and  that  the  relatively  low  recorded  morbidity-rate 
as  compared  with  the  mortality-rate  has  been  due  to  this  circumstance  rather 
than  to  neglect  on  the  part  of  physicians  to  report  their  cases  promptly.  In 
view  of  the  failure  of  the  active  measures  directed  over  so  many  years  to  the 
earlier  recognition  of  the  disease,  it  is  unlikely  that  anything  short  of  com¬ 
pulsory  physical  examination,  repeated  at  short  intervals,  of  every  individual 
in  the  community  would  materially  change  the  recorded  incidence  of  the 
disease. 

It  has  long  been  held  by  physicians  that  attacks  of  certain  acute  infectious 
diseases,  notably  measles,  scarlet  fever,  whooping-cough,  typhoid  fever,  and 
pneumonia,  predispose  to  tuberculosis.  In  a  general  way,  the  mortality-rates 
for  tuberculosis,  and  for  all  of  these  diseases  except  pneumonia,  have  declined 
together  since  1880.  To  the  degree  that  lowered  death-rates  indicate  either 
decreased  incidence  of  these  diseases  or  slighter  injury  to  those  who  survive 
attacks,  it  is  possible  that  this  association  may  he  significant.  On  a  parity  of 
reasoning,  the  decline  and  practical  disappearance  during  this  period  of  small¬ 
pox  and  malaria  and  typhus  fever,  all  of  which  severely  tax  the  system,  may 


FEBRILE  DISEASES 


415 


have  exerted  a  favorable  influence  upon  the  tuberculosis-rate.  The  period 
of  high  mortality  for  pulmonary  tuberculosis  between  1840  and  1880  was 
characterized  by  high  rates  for  nearly  all  of  these  diseases.  On  the  other 
hand,  the  fall  in  the  rates  for  pulmonary  tuberculosis  which  took  place  between 
1820  and  1840  occurred  when  the  rates  for  the  insect-borne  diseases  were  par¬ 
ticularly  high,  though  falling.  There  is  a  distinct  though  not  uniform  cor¬ 
respondence  in  the  curve  of  the  rates  for  tuberculosis  and  the  diarrhceal 
diseases,  and  particularly  for  those  for  dysentery  and  cholera.  The  curves  for 
pneumonia  and  pulmonary  tuberculosis  do  not  in  general  correspond  very 
closely. 

What  effects  upon  the  morbidity-  and  mortality-rates  may  be  attributed  to 
the  specific  efforts  put  forth  by  administrative  authority?  As  judged  by  the 
mortality-rate,  there  was  no  appreciable  effect.  The  total  death-rate  was  lower 
in  1899  before  anything  was  done  than  it  was  in  any  year  until  1915.  After 
1899  there  was  a  moderate  wave  of  increase  in  the  rates,  which,  reaching 
a  peak  in  1904,  had  in  its  decline  attained  by  1910  the  level  of  1900.  The 
anti-spitting  law  can  hardly  be  given  the  credit  for  this  slight  reaction.  During 
the  first  4  years  of  the  existence  of  the  tuberculosis  division,  the  mortality- 
rate,  when  the  deaths  among  Baltimore  cases  dying  at  the  extra -urban  sanatoria 
are  taken  into  account,  remained  practically  on  a  level.  The  slight  drop  in 
1915  to  the  level  of  1899  was  not  maintained.  In  spite  of  additional  nurses 
and  increased  activity  during  the  next  3  years,  the  rate  rose  steadily  to  the 
level  of  1905,  or  to  a  point  nearly  as  high  as  was  attained  at  the  peak  of  the 
last  wave,  and  considerably  higher  than  in  1899.  Upon  case  reporting  legal 
enactments  had  but  small  effect  until  the  establishment  of  the  tuberculosis 
division  in  1910.  It  has  been  shown  that  the  enormously  high  morbidity- 
rates  recorded  between  1910  and  1912  were  due  to  the  registration  of  large 
numbers  of  cases  previously  known  and  in  no  proper  sense  represented  actual 
current  newly  recognized  cases.  The  morbidity-curve,  which  since  1913  may 
justly  be  regarded  as  representing  the  current  morbidity  as  judged  by  the 
standard  of  reporting  in  vogue,  rises  and  falls  in  strict  consonance  with  the 
curve  for  mortality.  The  sudden  fall  in  both  mortality-  and  morbidity-rates 
since  1918,  a  duplication  of  a  phenomenon  characteristic  of  many  American 
cities  since  the  great  influenza  epidemic,  can  hardly  be  attributed  to  the  anti¬ 
tuberculosis  activities.  Mortality-rates  in  Baltimore  have  moved  in  the  same 
manner,  though  in  less  degree,  after  other  influenza  epidemics.  These  occur¬ 
rences  suggest  the  query,  whether  an  attack  of  influenza  does  not  protect  against 
tuberculosis. 

In  the  period  1910-1918,  the  nursing  force  had  charge  of  from  two-thirds 
in  the  early  period  to  four-fifths  in  the  latter  period  of  all  known  cases  of  the 
disease  for  instruction  in  prophylaxis.  During  much  of  the  period  not  less 
than  15  nor  more  than  20  per  cent  of  the  cases  of  the  moderately  advanced 
and  something  like  30  per  cent  of  the  cases  of  the  advanced  stage  were  hos¬ 
pitalized,  the  former  for  curative  treatment  and  the  latter  for  isolation  alone. 
So  far  as  benefits  derived  from  instruction  in  prophylaxis  are  concerned,  of 
the  active  cases  on  the  visiting-lists  in  1915,  a  typical  year,  17  per  cent  were 
recorded  as  adequately  careful,  41  per  cent  as  moderately  careful,  and  42  per 
cent  as  careless.  In  nearly  half  the  cases  the  results  of  instruction  were 
regarded  as  nihil.  It  is  safe  to  assume  that  the  cases  remaining  exclusively 


416  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

under  the  instruction  of  their  attending  physicians  were,  on  the  whole,  super¬ 
vised  and  instructed  at  least  as  thoroughly  and  conscientiously  as  were  those 
visited  by  the  nurses.  Nor  can  prophylactic  effects  of  any  considerable  value 
be  expected  from  fumigations  of  dwellings  at  the  termination  of  the  illness 
or  on  removal  of  individuals,  who  for  weeks,  months,  or  even  years  had  been 
emitting  myriads  of  tubercle  bacilli  daily. 

It  is  evident  from  table  88  that  the  part  played  by  the  tuberculosis  dispen¬ 
saries  of  the  health  department  in  diagnosis  and  treatment  was  relatively 
negligible.  The  only  other  special  dispensaries  for  tuberculosis  during  this 
period,  Phipps  and  the  University  of  Maryland,  represented  after  all  only 
separate  divisions  of  medical  clinics  long  in  operation.  Similarly,  the  opening 
of  the  Municipal  Tuberculosis  Hospital  on  Bay  View  grounds  did  not  amount 
to  a  great  deal  more  than  the  segregation  in  a  separate  building  of  about  the 
same  annual  number  of  advanced  cases  of  pulmonary  tuberculosis  that  in 
former  years  was  received  in  the  almshouse  and  infirmary  of  the  same  insti¬ 
tution.  The  three  extra-urban  sanatoria  were  indeed  new  institutions  opened 
since  1908.  Adequate  data  for  measuring  accurately  their  influence  upon  the 
course  of  pulmonary  tuberculosis  in  Baltimore  are  not  available.  An  average 
annual  hospital  death-rate  of  17  per  cent  among  the  selected  cases  admitted 
does  not  suggest  that  their  favorable  influence  was  striking. 

In  regard  to  other  forms  of  tuberculosis  from  1875  when  the  classification 
of  deaths  under  this  heading  first  approached  accuracy,  the  averaged  rates 
for  the  whole  population  fell  steadily  until  1895.  During  the  next  5  years 
they  reacted  to  a  somewhat  higher  level,  which  was  maintained  with  slight 
variations  until  1920.  In  the  20-year  period  from  1901  to  1920,  on  the  whole, 
the  rates  for  whites  declined  and  those  for  negroes  rose.  The  rates  for  females 
were  distinctly  lower  than  those  for  males  in  both  races.  The  rates  for  this 
rubric  declined  sharply  after  the  influenza  epidemic.  There  was  no  significant 
response  to  the  sanitary  improvements  which  characterized  this  period,  unless 
some  of  the  decline  since  1918  may  be  attributable  to  the  pasteurization  of  the 
milk-supply.  So  far  as  may  be  judged  from  the  data  at  hand,  the  action  of  the 
force  of  mortality  in  tuberculosis  of  the  lungs  and  of  other  organs  was  strik¬ 
ingly  similar. 

Advances  and  declines  in  the  death-rates  for  the  population  as  a  whole  have 
been  influenced  less  by  rapid  growth  in  the  population  per  se  than  by  changes 
in  the  relative  proportions  of  certain  race  stocks.  The  mortality-rate  has  been 
considerably  higher  in  negroes  than  in  whites  and  has  risen  with  the  increase 
and  fallen  with  the  decrease  in  the  proportion  of  Irish  and  Germans  in  the 
population.  The  rate  has  declined  notably  with  the  influx  of  Jews,  Italians, 
and  Poles.  The  evidence  that  the  mortality-rate  was  influenced  by  financial 
depression  and  by  prosperity  is  conflicting.  On  the  whole,  the  balance  of  the 
evidence  is  in  favor  of  the  view  that  it  was  unfavorably  affected  by  financial 
depression.  It  is  more  than  possible  that  increase  in  the  quantity  of  the  milk- 
supply  since  1880  may  have  exerted  a  favorable  influence.  Whereas  the 
mortality-rate  did  decline  synchronously  with  sanitary  improvements  at  certain 
times,  e.  g.,  after  the  water-supply,  sewerage  disposal,  paving,  and  the  like  had 
undergone  distinct  improvements  between  1820  and  1840,  and  the  water- 
supply  again  after  1865,  and  after  1880,  this  must  apparently  be  attributed 
to  other  causes,  for  there  was,  on  the  whole,  no  significant  decline  in  the  annual 
mortality-rates  in  this  period  from  1900  to  1918,  during  which  time  the  most 


FEBRILE  DISEASES 


417 


extensive  improvements  were  made  in  general  sanitation,  in  regard  to  water, 
sewage,  garbage  collection,  and  general  nuisance  control,  paving,  milk  inspec¬ 
tion,  federal  inspection  of  meats  and  the  anti-spitting  ordinance.  While  in 
this  analysis  it  has  not  been  possible  to  determine  any  positive  beneficial  effects 
upon  the  tuberculosis  mortality-rate  to  be  ascribed  to  the  in  many  ways  pro¬ 
found  and  far-reaching  modifications  of  environment,  which  have  included 
every  extreme  except  those  induced  by  siege  and  famine,  the  possibility  or 
even  probability  of  a  negative  influence  may  not  be  denied.  For  instance,  it 
can  not  be  claimed  that,  in  the  absence  of  the  general  sanitary  reforms  and 
the  restrictive  and  educational  measures  directed  specifically  against  tubercu¬ 
losis  introduced  after  1895,  and  which  reached  their  climax  about  1918,  the 
waves  of  higher  rates  which  were  due  and  which  actually  started  after  1899  and 
1912  would  not  have  reached  much  higher  levels  than  were  attained. 

There  are  rather  definite  indications  which  suggest  that  the  course  of  tuber¬ 
culosis  has  been  influenced  unfavorably  by  attacks  on  the  community  of  cer¬ 
tain  acute  communicable  diseases  and  affected  favorably  by  the  decline  in  the 
virulence  of  some  and  the  practical  disappearance  of  others. 

Whatever  the  causes  of  the  decline  in  the  mortality  from  pulmonary  tuber¬ 
culosis  may  be,  they  have  acted  uniformly  as  to  time,  though  not  in  the  same 
degree,  upon  males  and  females  in  both  the  white  and  colored  races.  Since 
about  1880,  the  curves  for  both  races  have  followed  almost  identical  courses, 
though  at  different  levels.  In  periods  of  decline,  in  both  races  the  rates  for 
females  have  fallen  more  sharply  than  those  for  males.  WTiile  with  the  decline 
in  the  rates  for  all  ages  in  each  category,  the  rates  for  each  age-group  have 
dropped,  the  decrease  in  mortality  has  been  most  conspicuous  in  the  age- 
groups  before  the  thirtieth  year  of  life.  The  available  data  indicate  that  in 
regard  to  color  and  sex  the  age  distribution  of  reported  cases  and  deaths  has 
been  in  close  accord. 

These  close  associations  suggest  very  strongly  that  the  causes  which  control 
both  incidence  and  fatality  of  pulmonary  tuberculosis  and  which  act  in  the 
same  manner  though  in  such  different  degree  in  both  races  and  sexes  are 
fundamentally  biological.  However,  this  may  be,  the  only  positive  evidence 
adduced  indicates  unmistakably  that  the  rise  and  fall  in  the  rate  for  tubercu¬ 
losis  in  Baltimore  during  the  109  years  embraced  in  this  study  have  been 
determined  above  all  other  factors  by  natural  selection,  and  that  in  this  strug¬ 
gle  between  parasite  and  host  under  very  varied  and  complex  changes  of 
terrain  as  represented  by  environment,  and  of  the  belligerents  themselves  as 
represented  by  recruits,  in  the  shape  of  new  races  as  well  as  by  discipline  and 
training,  the  advantage  has  been  sometimes  with  the  one  and  sometimes  with 
the  other.  In  these  respects  tuberculosis  has  behaved  in  many,  if  not  in  most 
wavs  like  several  other  readily  communicable  diseases  whose  courses  have  been 
followed  in  this  work.  In  1917,  on  the  basis  of  data  presented  in  this  chapter, 
the  writer  was  forced  to  the  conclusion  that  the  real  significance  of  the  various 
factors  concerned  in  human  tuberculosis  can  not  be  ascertained  with  the 
incomplete  and  superficial  knowledge,  relatively  inaccurate  methods,  and  the 
illogical  reasoning  hitherto  so  commonly  brought  to  bear  upon  the  question. 
Nothing  short  of  an  exhaustive  study  of  the  genetic  and  environmental  history 
of  a  very  large  number  of  cases  promised  a  solution,  and  in  1919,  at  the 
writer’s  suggestion,  Professor  Raymond  Pearl  undertook  such  an  investigation 
of  the  Baltimore  material. 


Chapter  XII. — Other  Acute  Febrile  Diseases, 
Some  Apparently  Contactive. 


Acute  meningitis;  Poliomyelitis;  Tetanus;  Erysipelas;  Appendicitis. 

(Tables  91  to  100  and  34,  128,  131.) 

ACUTE  MENINGITIS. 

In  the  local  statistical  nosology,  the  rubric  cerebro-spinal  meningitis  ap¬ 
peared  in  1872,  coincident  with  an  outbreak  of  the  so-called  epidemic  men¬ 
ingitis.  Three  years  later*  the  rubrics  meningitis  and  tuberculous  meningitis 
were  added.  Before  1872  meningitis  of  various  types  was  probably  classfied 
for  the  most  part  under  such  indefinite  headings  as  inflammation  of  the  brain, 
dropsy  of  the  brain,  and  convulsions,  and  probably  not  until  1900  were  deaths 
due  to  inflammation  of  the  meninges  classified  with  approximate  precision 
under  the  appropriate  rubrics.  Of  the  affections  most  likely  to  be  confused 
with  acute  meningitis,  the  most  prominent  are  brain  tumor,  brain  abscess, 
uraemia,  and  the  intoxications  of  certain  acute  infectious  diseases,  such  as 
typhoid  fever  and  pneumonia.  The  first  specific  type  of  acute  meningitis 
to  be  recognized  anatomically  and  etiologically  with  certainty  was  the  tuber¬ 
culous.  Though  this  form  has  been  included  in  the  discussion  of  tuberculosis, 
it  will  be  necessary  to  allude  to  it  here.  Of  non-tuberculous  acute  meningitis 
three  types  may  be  recognized:  The  specific  disease  due  to  meningococcus 
intracellularis  meningitidis,  the  so-called  epidemic  meningitis,  which  is  not 
infrequently  sporadic  also ;  primary  meningitis  of  other  but  very  diverse  etiol¬ 
ogy,  caused  for  the  most  part  by  the  pyogenic  cocci,  but  occasionally  by  other 
identified  micro-organisms  and  by  unknown  causes;  and  secondary  meningitis 
occurring  as  a  complication  of  wound  infection,  endocarditis,  arterial  and 
venous  thrombosis,  middle-ear  disease,  brain  abscess,  typhoid  fever,  pneumonia, 
the  eruptive  diseases,  and  injuries  of  various  kinds,  particularly  of  the  skull.  It 
is  manifest  that  these  types  were  not  differentiated  in  the  statistical  classifica¬ 
tion  and  that  meningitis  and  cerebro-spinal  meningitis  must  have  included 
the  epidemic  type,  primary  and  secondary  non-tuberculous  meningitis  of  other 
etiology,  and  some  deaths  from  tuberculous  meningitis. 

It  is  probable  that  fewer  mistakes  were  made  in  the  classification  of  deaths 
from  tuberculous  meningitis,  and  that,  on  the  whole,  the  figures  for  this  rubric 
since  1880  reflect  actual  occurrence  with  a  fair  degree  of  accuracy.  It  is  likely 
that,  particularly  in  times  of  epidemic  outbreaks,  the  specific  meningococcus 
meningitis  was  as  a  rule  classified  under  the  rubric  cerebro-spinal  meningitis. 
The  rubric  meningitis,  which  has  carried  the  largest  proportion  of  the  deaths 
ascribed  to  acute  inflammation  of  the  meninges,  has  undoubtedly  included 
many  of  the  deaths  from  meningococcus  meningitis,  some  deaths  due  to  tubercu¬ 
losis,  and  most  of  those  due  to  primary  and  secondary  meningitis  of  other 
causation.  The  annual  mortality  from  meningitis,  as  classified  under  those 
various  headings,  with  the  total  mortality  from  all  forms  and  from  men¬ 
ingitis  and  cerebro-spinal  meningitis  combined,  is  presented  in  table  91.  It 

418 


FEBRILE  DISEASES 


419 


will  be  noted  that  the  rates  for  tuberculous  meningitis,  beginning  with  27 
in  1875,  attained  33,  its  highest  level,  in  1877,  and  fell  gradually  by  somewhat 
irregular  steps  to  15  in  1885.  After  holding  about  this  level  during  the  next 
4  years  and  rising  to  22  in  1890,  it  ran  an  uneven  course,  with  rates  varying 
between  11  and  17,  until  1904.  With  the  exception  of  1905  and  1911,  when 
the  rates  were  6  and  15,  respectively,  the- annual  rate  varied  between  10  and 
13  until  1919.  In  the  latter  year  it  was  9,  and  in  1920  it  fell  to  5.  The  fluctua¬ 
tion  in  the  annual  rate  was  not  wide  and  did  not  synchronize  with  changes 
in  the  rate  for  the  other  rubrics.  On  the  whole,  the  impression  is  given  of 
an  independent  disease  with  rates  falling  gradually,  though  somewhat  irregu¬ 
larly,  from  a  peak  in  1879  to  a  relatively  low  level  by  1920. 

While  the  number  of  deaths  ascribed  to  cerebro-spinal  meningitis  fell  far 
short  of  the  whole  number  that  must  have  been  caused  by  epidemic  or  men¬ 
ingococcus  meningitis,  it  is  probable  that  the  rates  reflect,  with  some  accuracy, 
the  general  course  of  that  disease  as  measured  in  terms  of  mortality.  It  would 
appear  that  this  affection  was  present  each  year  between  1872  and  1910,  and 
that  upon  the  endemic  basis  that  followed  the  epidemic  beginning  about  1872, 
the  course  of  the  disease  lias  been  marked  by  several  exacerbations,  or  epi¬ 
demic  outbreaks,  the  severest  of  which  were  those  of  1881-1883,  1898-1900, 
and  1917-1918.  Between  1910  and  1912,  inclusive,  the  affection  apparently 
died  out.  The  outbreak  of  1917-1918,  which  fell  under  the  writer’s  observa¬ 
tion,  during  which  all  reported  cases  were  investigated  bacteriologically,  was 
shown  to  be  due  to  meningococcus  intracellularis  meningitidis. 

The  rates  for  the  rubric  meningitis,  supposedly  representing  chiefly  deaths 
from  primary  and  secondary  meningitis  of  other  origin  than  the  tuberculous 
and  the  meningococcus  forms,  are  markedly  higher  than  those  for  these  other 
rubrics.  As  compared  with  the  other  two  rubrics,  its  course  manifests  a  cer¬ 
tain  degree  of  correlation  in  that  very  commonly  years  in  which  it  registered 
higher  rates  synchronized  with  years  of  lower  rates  for  one  or  for  both  of  the 
others,  and  years  of  rising  rates  for  them  showed  lower  or  falling  rates  for  it. 
This  picture  suggests  that,  to  some  degree  at  least,  the  fluctuation  in  the  rates 
for  these  three  rubrics  was  determined  by  statistical  classification.  However, 
this  may  be,  the  rates  for  meningitis  rose  from  26  in  1875  to  39  in  1879,  and, 
holding  at  about  the  latter  level  for  the  next  two  years,  ascended  to  47  in 
1881.  Falling  by  uneven  steps  during  the  succeeding  6  years,  the  rate  stood 
at  34  in  1887,  and  from  this  it  rose  in  1892  to  49,  the  highest  point  attained. 
From  this  date  the  trend  of  the  curve  is  downward.  The  annual  rate  was 
never  as  high  as  40  after  1898,  25  after  1902,  nor  20  after  1910.  Since  1912 
the  rate  has  declined  steadily  to  3  in  1920. 

The  sum  of  the  rates  for  meningitis  and  cerebro-spinal  meningitis  may  be 
regarded  as  in  the  main  representative  of  the  death-rates  for  non-tuberculous 
meningitis.  If  this  be  true,  the  tuberculous  form  has  been,  during  most  of  the 
period  under  consideration,  a  relatively  unimportant  cause  of  death.  The 
curve  of  the  rates  for  non-tuberculous  meningitis,  after  holding  a  high  level — 
between  40  and  58  from  1875  to  1901 — fell  continuously  to  the  low  level  of 
6  in  1920.  The  rate  for  tuberculous  meningitis  had  by  1900  fallen  to  11, 
which  was  maintained  on  an  average  until  1919,  without  any  significant 
further  fall. 


Table  91—  Number  of  deaths  and  rate  of  death ,  per  100,000  living  inhabitants,  from  erysipelas,  tetanus  and  acute  diseases  of  central  nervous 

system,  from  1812  to  1920,  inclusive. 

D  =  death.  R  =  rate. 


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Table  91. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from  erysipelas,  tetanus  and  acute  diseases  of  central  nervous 

system,  from  1812  to  1920,  inclusive. — Continued. 


422 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


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FEBRILE  DISEASES 


423 


The  sum  of  the  rates  for  the  three  rubrics  indicates  with  some  degree  of 
accuracy  the  course  of  the  mortality  for  the  acute  infections  inflammatory 
affections  of  the  cerebro-spinal  meninges  during  the  46  years  under  considera¬ 
tion.  During  the  first  25  years  the  course  of  the  curve  of  mortality  varied 
between  79  and  54.  Between  1900  and  1915  the  rates  fell  almost  without 
interruption  from  54  to  17.  During  the  next  3  years,  owing  to  a  recrudescence 
of  epidemic  meningitis,  the  rate  rose  to  25,  to  fall  to  18  in  1919  and  to  11 
in  1920. 

When  the  irregular  annual  fluctuations  in  the  rates  for  these  three  rubrics 
are  smoothed  by  averaging  for  5-year  periods  (table  92),  very  much  the  same 


Table  92. — Average  rate  of  death,  -per  100,000  living  inhabitants,  by  5-year  periods, 
from  acute  diseases  of  the  central  nervous  system,  from  1812  to  1920,  inclusive. 


Periods. 

Meningitis. 

Poliomyelitis. 

Dropsy  in  the 
head. 

Inflammation  of 

the  brain. 

Spinal  affections 

and  dropsy  of 

the  spine. 

Total,  excluding 

tuberculous 

meningitis. 

Grand  total. 

Meningitis. 

Cerebro¬ 

spinal. 

Total. 

Tuberculous. 

All  forms. 

1812-15  . 

... 

•  •  • 

•  •  • 

•  •  • 

1816-20  . 

•  •  • 

23 

12 

35 

35 

1821-25  . 

39 

23 

62 

62 

1826-30  . 

33 

19 

52 

52 

1831-35  . 

44 

31 

74 

74 

1836-40  . 

• 

35 

24 

59 

59 

1841-45  . 

40 

24 

64 

64 

1846-50  . 

. . . 

33 

49 

1 

83 

83 

1851-55  . 

... 

60 

79 

6 

145 

145 

1856-60  . 

41 

72 

6 

119 

119 

1861-65  . 

26 

63 

5 

94 

94 

1866-70  . 

•  •  • 

40 

69 

6 

114 

114 

1871-75  . 

18 

18 

5 

23 

26 

78 

14 

136 

141 

1876-80  . 

35 

9 

44 

30 

74 

14 

14 

1 

73 

103 

1881-85  . 

43 

9 

52 

19 

71 

9 

8 

68 

87 

1886-90  . 

38 

6 

44 

17 

61 

6 

8 

57 

74 

1891-95  . 

40 

7 

47 

L5 

62 

4 

7 

59 

74 

1896-1900  ... 

35 

12 

47 

13 

60 

3 

3 

54 

67 

1901-05  . 

23 

6 

29 

11 

40 

•  •  • 

1 

30 

41 

1906-10  . 

21 

4 

25 

11 

36 

•  •  • 

1 

25 

36 

1911-15  . 

13 

1 

14 

12 

26 

1 

15 

27 

1916-20  . 

3 

7 

10 

9 

19 

3 

•  •  • 

1 

14 

23 

picture  is  obtained.  The  averaged  rate  for  tuberculous  meningitis  fell  from 
30  in  1876-1880  to  19  in  1881-1885,  to  13  in  1896-1900,  and  to  11  in  1901- 
1905.  Between  1900  and  1920  it  remained  almost  constant,  and  the  slight 
drop  during  the  last  5  years  is  hardly  significant.  The  averaged  rate  for 
cerebro-spinal  meningitis  fell  from  its  high  level  of  18  in  1871-1875  to  9  in 
1876-1880,  remained  unchanged  during  the  next  5  years,  and  between  1886 
and  1890  dropped  to  6.  Ascending  to  12,  a  second  high  level  between  1891 
and  1900,  the  averaged  rate  descended  continuously  to  1  between  1911  and 
1915.  From  1916  to  1920  the  rates  averaged  7.  The  averaged  rate  for  men¬ 
ingitis,  unqualified  or  so-called  simple  meningitis,  which  was  35  for  the 
period  ending  in  1880,  rose  to  43  for  the  next  5  years.  Varying  but  slightly 


424  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

from  this  level  from  1886  to  1895  it  returned  to  the  initial  level  of  35  between 
1896  and  1900.  From  1901  to  1920  the  rate  declined  steadily  to  3.  It  will 
be  noted  that  simple  meningitis  and  cerebro-spinal  meningitis  fell  together 
between  1901  and  1915,  and  that  between  1916  and  1920  the  former  con¬ 
tinued  to  fall  uninterruptedly,  while  the  latter  rose.  Since  1900,  in  the  statis¬ 
tical  nosology,  the  latter  has  represented  the  meningococcus  form  and  the 
former  acute  non-tuberculous  meningitis  of  other  etiology.  This  separation 
was  made  with  reasonable  clearness  from  1900  to  1915  and  with  considerable 
accuracy  between  1916  and  1920.  Therefore,  the  course  of  the  curves  for 
these  two  rubrics  during  the  past  20  years  may  be  taken  to  represent  the 
respective  lethal  importance  of  these  two  types  of  meningitis.  The  curve  of 
the  averaged  rates  for  these  two  types  taken  together  rose  steadily  from  18  for 

Table  93. — Number  of  cases  and  monthly  annual  rate  of  morbidity,  per  100,000  living 
inhabitants,  from  epidemic  (meningococcus)  meningitis,  from  1916  to  1920,  inclusive. 


C  =  cases.  R  =  rate. 


1916 

1917 

1918 

1919 

1920 

C 

R 

C 

R 

C 

R 

C 

R 

C 

R 

J  an . 

1 

2 

•  •  • 

•  •  • 

13 

25 

14 

23 

4 

6 

Feb . 

23 

49 

14 

25 

4 

7 

Mar . 

17 

33 

27 

51 

6 

10 

6 

10 

Apr . 

3 

6 

20 

40 

36 

71 

4 

7 

4 

7 

May  . 

1 

2 

37 

71 

19 

36 

1 

2 

4 

6 

.Tnrip  . 

23 

46 

8 

16 

4 

7 

4 

7 

July  . 

3 

6 

5 

10 

13 

25 

4 

7 

2 

3 

Aug . 

4 

8 

2 

4 

8 

15 

10 

16 

3 

5 

Sppt, . 

2 

4 

5 

10 

1 

2 

Oct . 

2 

4 

2 

4 

8 

15 

3 

5 

•  •  • 

Nov . 

7 

14 

10 

20 

3 

5 

2 

3 

Dec . 

2 

4 

7 

13 

5 

10 

4 

7 

3 

5 

Total  . 

16 

3 

122 

20 

175 

28 

68 

9 

36 

5 

Percentage  case  fatality . 

48 

43 

57 

69 

the  period  ending  in  1875  to  52  for  the  5  years  ending  in  1885,  deviated  but 
slightly  from  a  level  of  about  45  to  1900,  and  descended  sharply  during  the 
succeeding  20  years. 

The  lethal  force  of  all  forms  of  meningitis  rose  sharply  to  its  peak  in  the 
5  years  ending  in  1885,  and,  declining  gradually  during  the  following  15 
years,  fell  conspicuously  between  1901  and  1920.  During  these  20  years  acute 
inflammation  of  the  meninges  fell  from  the  position  of  a  principal  cause  of 
death  to  one  of  comparative  insignificance.  This  decline  was  due  to  but  small 
degree  to  changes  in  the  rate  for  tuberculous  meningitis,  which  during  most 
of  the  period  held  an  almost  constant  level. 

Epidemic  or  meningococcus  meningitis  was  not  reported  with  any  regu¬ 
larity  until  1917.  It  will  be  noted  (tables  93  and  94)  that  in  1916  the  deaths 
exceeded  the  reported  cases  in  number.  Since  the  fall  of  1916  special  pressure 
has  been  brought  to  bear  to  secure  early  and  full  case  reporting,  and  isolation 
of  cases  and  contacts  has  been  imposed.  Since  this  time  the  diagnosis  has  de- 


FEBRILE  DISEASES 


425 


pended  upon  the  demonstration  of  the  meningococcus  by  lumbar  puncture  dur¬ 
ing  life  or  at  autopsy  in  fatal  cases,  and  the  contacts  have  been  confined  or 
released  accordingly  as  this  organism  was  demonstrated  or  not  in  cultures  made 
from  the  nose  and  throat.  All  or  nearly  all  of  the  cases  were  treated  with  anti- 
meningococcus  serum  and  a  large  proportion  of  the  cases  was  hospitalized. 
For  the  4-year  period,  1917-1920  inclusive,  the  data  at  hand  as  set  forth  in 
table  93  may  be  regarded  as  exact.  During  this  period  the  deaths  ascribed 
to  simple  meningitis  (rubric  61)  were  proven  by  the  use  of  bacteriological 
methods  to  be  due  to  organisms  other  than  the  meningococcus.  In  this  4-year 
period  no  secondary  cases  of  meningococcus  meningitis  were  observed  among 
contacts,  either  in  families  or  institutions.  Several  cases  in  1917  occurred 
among  a  detachment  of  militiamen,  recently  recruited,  and  all  from  the  city. 

Table  94. — Number  of  deaths  and  monthly  annual  rate  of  mortality,  per  100,000  living 
inhabitants,  from  epidemic  (meningococcus)  meningitis,  from  1916  to  1920,  inclusive. 


D  =  death.  R  =  rate. 


1910 

1917 

1918 

1919 

1920 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

Jan . 

2 

4 

3 

6 

5 

10 

4 

7 

2 

3 

Feb . 

2 

4 

1 

2 

5 

11 

8 

14 

2 

4 

Mar . 

3 

6 

5 

10 

15 

29 

5 

8 

6 

10 

Apr . 

10 

20 

14 

28 

4 

7 

3 

5 

May  . 

1 

2 

13 

25 

11 

21 

2 

3 

1 

2 

June  . 

2 

4 

10 

20 

6 

12 

1 

2 

3 

5 

J  uly  . 

2 

4 

7 

13 

6 

11 

3 

5 

1 

2 

Aug . 

2 

4 

1 

2 

5 

10 

3 

5 

2 

3 

Sept . 

1 

2 

1 

2 

2 

3 

Oct . 

1 

2 

5 

10 

3 

5 

Nov . 

3 

6 

1 

2 

4 

7 

2 

3 

Dec . 

3 

6 

3 

6 

2 

4 

2 

3 

1 

2 

Total  . 

18 

3 

58 

9 

75 

12 

39 

5 

25 

3 

The  sick  and  their  contacts  were  at  once  isolated  and  the  disease  failed  to 
extend  among  the  command.  Whatever  advantages  may  have  been  gotten  by 
handling  this  disease  with  the  same  method  used  in  diphtheria  have  been 
reaped. 

It  may  be  significant  that  the  death-rate  was  appreciably  lower  in  this  out¬ 
break  than  in  that  of  1898-1901.  However,  the  favorable  showing  was  per¬ 
haps  in  largest  part  due  to  the  curative  effects  of  the  serum,  rather  than  to 
isolation  methods.  The  case-fatality  rates  among  the  reported  cases  was 
48,  43,  57,  and  69  per  cent  for  the  respective  years.  In  other  words,  it  is 
probable  that  the  mortality-  rather  than  the  morbidity-rates  were  favorably 
affected  by  the  introduction  of  the  new  methods.  The  influence  of  season  upon 
incidence  is  striking.  In  the  4-year  period  1917-1920,  during  which  the 
diagnosis  of  meningococcus  meningitis  was  established  with  exactness,  the 
peak  of  both  morbidity  and  mortality  (table  94)  occurred  in  later  winter 
months  or  spring,  February,  March,  April,  or  May.  In  these  years  there  was 
a  recrudescence  of  the  disease  in  the  early  summer,  and  in  1919  this  was  con¬ 
spicuous.  The  disease,  like  the  acute  exanthematous  diseases,  dies  down  during 


426  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


the  hot  months,  springs  up  in  the  fall,  and  steadily  increases  in  prevalence 
during  the  winter  months.  The  decline  from  the  peak  may  be  gradual  or 
abrupt.  In  general,  the  course  of  the  morbidity  and  mortality  curves  follow 
each  other  closely. 

For  the  3  years  for  which  data  exist  for  comparing  the  influence  of  color  and 
sex  upon  mortality  (table  95)  there  were  no  significant  differences  for  color, 
in  fact,  the  averaged  mortality-rates  were  the  same  for  both  whites  and 
negroes.  The  mortality-rates  were  distinctly  greater  in  males  than  in  females 
of  both  races,  and  this  difference  was  much  more  marked  in  negroes  than 
in  whites. 

The  death-rate  from  tuberculous  meningitis  had  already  made  its  signifi¬ 
cant  decline  before  the  inauguration  of  the  inadequate  reforms  in  the  con¬ 
trol  of  the  milk-supply  between  1896  and  1918,  and  during  this  period  it 
remained  practically  unchanged.  Nor  does  it  appear  that  on  the  average  the 
rate  was  favorably  influenced  by  the  other  activities  of  the  department  of 
health  exercised  through  nurses  and  propaganda,  for  the  death-rate  from  this 

Table  95. — Number  of  deaths  and  rate  of  mortality,  per  100,000  living  inhabitants,  from 
epidemic  (meningococcus)  meningitis,  according  to  color  and  sex,  from  1918  to 
1920,  inclusive. 

D  =  death.  R  =  rate. 


Year. 

Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1918  . 

75 

12 

63 

12 

34 

13 

29 

11 

12 

12 

10 

22 

2 

4 

1919  . 

39 

5 

35 

6 

20 

7 

15 

5 

4 

4 

2 

4 

2 

4 

1920  . 

25 

3 

20 

3 

10 

3 

10 

3 

5 

5 

3 

6 

2 

4 

form  of  tuberculosis  was  as  low  between  1900  and  1910  as  it  was  between  1911 
and  1918.  It  is  quite  possible  that  the  considerable  decline  in  the  rate  which 
occurred  in  1919  and  1920  was  due  in  part  at  least  to  the  enforcements  of 
proper  pasteurization  of  milk. 

No  attempt  has  ever  been  made  by  the  health  department  to  erect  barriers 
against  the  spread  of  simple  meningitis.  Restrictive  measures  were  not  applied 
to  the  spread  of  epidemic  or  meningococcus  meningitis  until  1917,  when  isola¬ 
tion  of  cases  and  carriers  was  instituted,  and  anti-meningococcus  serum 
obtained  from  the  New  York  City  Board  of  Health  was  furnished  freely  for 
treatment  of  proven  cases. 

It  is  clear  from  the  foregoing  that  from  1875  to  1916  the  course  of  acute 
meningitis  was  uninfluenced  by  any  artificial  interferences  instituted  by  the 
health  department,  and  that  the  curve  of  mortality  reflects  during  this  period 
the  natural  history  of  acute  inflammatory  affections  of  the  cerebro-spinal 
meninges  on  the  population.  For  meningococcus  meningitis  the  facts  at  hand 
warrant  the  inference  that  from  1917  to  1920  the  incidence  of  the  disease  may 
have  been  diminished  by  restricted  measures  and  the  mortality-rates  influenced 
favorably  to  some  degree  by  the  use  of  anti-serum  freely  dispensed. 


FEBRILE  DISEASES 


427 


So  much  for  the  picture  of  the  course  of  meningitis  as  it  may  be  drawn 
from  the  recorded  deaths  classified  under  rubrics  specifically  indicating  in¬ 
flammation  of  the  brain  membrane.  In  regard  to  repositories  for  deaths  due 
to  inflammation  of  the  meninges  before  1872,  the  statistical  nosology  con¬ 
tained,  both  before  and  after  this  date,  several  rubrics  under  which  such  deaths 
must  have  been  allocated.  Of  these,  the  most  important  are  inflammation  of 
the  brain,  dropsy  in  the  head,  hydrocephalus,  spinal  affection,  and  dropsy 
of  the  spine.  To  the  rubric  inflammation  of  the  brain,  deaths  were  ascribed 
each  year  (with  the  exception  of  1817  and  1902)  from  1816  to  1920.  With 
comparatively  slight  variation  from  year  to  year,  the  number  of  deaths  cred¬ 
ited  to  this  rubric  increased  gradually  from  14  in  1818  to  164  in  1853,  221  in 
1869,  283  in  1871,  and  292  in  1872.  The  number  of  deaths  declined  to  241 
in  1873,  to  52  in  1875,  and  to  31  in  1880.  Expressed  in  relative  terms,  the 
rate  for  this  rubric  rose  from  26  in  1818  to  102  in  1872  and,  coincidently 
with  the  introduction  of  the  rubrics  for  meningitis,  fell  abruptly  to  17  in  1875 
and  to  9  in  1880.  Between  the  latter  date  and  1898,  when  it  stood  at  3,  the 
annual  rate  for  inflammation  of  the  brain  never  rose  above  6.  As  in  the 
light  of  present  knowledge  and  of  the  experiences  of  pathological  anatomists, 
since  the  middle  of  the  nineteenth  century  at  least,  it  is  inconceivable  that 
the  high  mortality-rates  obtaining  for  inflammation  of  the  brain  before  1875 
could  have  represented  inflammatory  affections  of  the  substance  of  this  organ, 
the  inference  is  that  the  greater  moiety,  if  not  most,  of  the  deaths  ascribed  to 
this  rubric  were  due  to  meningitis.  Between  1816  and  1874,  deaths  were 
assigned  to  dropsy  in  the  head  in  each  year  except  1825,  1826,  1846,  and  1847. 
In  occasional  years  the  rubric  hydrocephalus  also  occurred.  x\£ter  1874,  dropsy 
in  the  head  disappeared  and  gave  place  permanently  to  the  rubric  hydro¬ 
cephalus.  It  is  well  established  that  those  two  terms  were  used  to  embrace 
meningitis  of  different  kinds,  that  with  exudates  in  both  the  meninges  and 
the  ventricles  of  the  brain,  as  well  as  the  ordinary  congenital  hydrocephalus 
and  the  various  relatively  rare  types  of  internal  and  external  hydrocephalus 
unassociated  -with  acute  inflammation  developing  after  birth.  Dropsy  in  the 
head  and  hydrocephalus  had  attained  a  death-rate  of  49  by  1819,  and  between 
this  date  and  1874  the  annual  rate  varied  within  wide  limits,  the  highest  being 
90  in  1854  and  the  lowest  14  in  1863  and  1864.  From  58  in  1823,  the  annual 
rate  had  fallen  to  18  in  1875  and  to  8  in  1882,  and  since  the  latter  date  it  has 
fallen  steadily  to  2  in  1900,  a  rate  which  probably  represents  the  extreme  for 
the  congeries  of  affections  now  classified  under  hydrocephalus.  There  is  less 
certainty  in  regard  to  the  significance  of  the  rubrics  spinal  affection  and 
dropsy  of  the  spine,  to  which  there  were  ascribed  a  few  deaths  between  1850 
and  1870  and  as  many  as  57  and  58  in  1872  and  1873,  respectively,  and  which 
disappeared  after  the  rubrics  for  meningitis  were  firmly  established. 

In  table  92  are  presented  the  average  quinquennial  rates  from  1816  to  1920 
for  these  various  rubrics  separately  and  combined.  Under  the  rubrics  dropsy 
in  the  head  and  inflammation  of  the  brain,  in  so  far  as  they  may  be  taken  to 
represent  meningitis,  some  relatively  slight  deductions  must  be  made  from  the 
first  for  true  hydrocephalus  in  the  present  use  of  the  term  and  from  the  second 
for  the  comparatively  rare  acute  inflammation  of  the  brain  substance. 

28 


428  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

The  decline  in  the  rates  for  dropsy  in  the  head  and  inflammation  of  the 
brain  after  the  introduction  of  meningitis  into  the  statistical  nosology  was 
so  marked  that  the  conclusion  is  forced  that  previous  to  1900  the  two  former 
rubrics  not  only  included  the  latter,  but  that  the  combined  rates  for  these 
rubrics  must  reflect  with  some  degree  of  accuracy  the  course  of  mortality  for 
meningitis  from  1816  to  1900.  Viewed  in  this  light,  it  would  appear  that  during 
this  period  meningitis,  though  subject  to  several  waves  of  rise  and  decline  in 
mortality,  was  continuously  a  potent  cause  of  death.  The  period  of  highest 
averaged  rates  was  between  1851  and  1880,  with  the  peak  (a  rate  of  145) 
during  the  quinquennium  1851-1855.  The  relatively  high  rates  obtaining  up 
to  1900  were  probably  due  to  tuberculous  meningitis,  meningocoecus  men¬ 
ingitis,  and  to  the  prevalence  in  virulent  form  of  such  diseases  as  measles, 
scarlet  fever,  and  wound  infections,  in  which  the  so-called  simple  meningitis 
is  apt  to  occur  as  a  secondary  complication.  Similarly,  the  considerable  fall 

Table  96. — Number  of  deaths  and  of  reported  cases  of  poliomye¬ 
litis  and  rates  of  mortality  and  of  morbidity,  per  100,000 
living  inhabitants,  for  years  1912  to  1920  and  1915  to  1920, 
respectively ,  and  the  percentage  of  case  fatality  for  the 
years  1915  to  1920,  inclusive. 


Year. 

Cases. 

Rate. 

Deaths. 

Rate. 

Per  cent, 
case 

fatality. 

1912  . 

•  •  • 

•  •  • 

6 

1 

•  •  • 

1913  . 

•  •  • 

•  •  • 

1 

0 

•  •  • 

1914  . 

•  •  • 

•  •  • 

2 

0 

•  •  • 

1915  . 

26 

4 

4 

1 

15 

1916  . 

206 

34 

70 

12 

34 

1917  . 

2 

0 

0 

0 

0 

1918  . 

38 

6 

5 

1 

13 

1919  . 

83 

12 

28 

4 

34 

1920  . 

15 

2 

4 

1 

27 

Total  . 

370 

. . . 

120 

•  •  • 

30 

in  the  total  rate  for  acute  diseases  of  the  nervous  system  since  1880  may  be 
attributed  partly  to  an  active  decline  in  the  mortality  from  tuberculous  and 
meningococcus  meningitis,  partly  to  decrease  in  the  virulence  of  the  diseases 
with  which  simple  meningitis  is  a  complication,  and  partly  to  gradual  increase 
in  the  accuracy  of  classification  of  deaths  to  appropriate  rubrics. 

POLIOMYELITIS. 

This  disease  was  first  recognized  in  the  statistical  nosology  in  1912,  and 
since  that  date  it  has  been  credited  with  one  or  more  deaths  in  each  year  except 
1917.  In  the  latter  year  2  cases  were  reported.  It  is  certain,  therefore,  that 
cases  of  the  disease  occurred  each  year  during  this  9-year  period.  In  table  96 
are  given  the  data  for  mortality  since  1912  and  for  morbidity  and  case  fatality 
since  1915.  The  number  of  reported  cases  does  not  reflect  accurately  the  true 
incidence  of  the  disease,  for  some  mild  and  doubtful  cases  were  certainly  over¬ 
looked.  The  number  of  recorded  deaths  represents  actual  experience  with  a 
fair  degree  of  correctness.  The  data  for  the  epidemic  of  1916  are  of  unusual 


FEBRILE  DISEASES 


429 


accuracy,  for  shortly  after  the  beginning  of  the  outbreak  all  reported  cases 
were  seen  by  trained  diagnosticians,  and  in  all  fatal  cases  careful  autopsies, 
with  histological  examination  of  the  central  nervous  system,  were  made  by 
Dr.  Mont  Burroughs,  of  the  Pathological  Laboratory  of  the  Johns  Hopkins 
University  and  Hospital,  or  under  his  direction.  In  succeeding  years  all 
reported  cases  have  been  investigated,  and  autopsies  have  been  held  in  fatal 
cases  in  which  the  diagnosis  was  in  doubt. 

A  striking  characteristic  of  poliomeylitis  has  been  the  regularity  of  its 
rise  and  decline  in  wave-like  fashion.  During  the  9  years  three  such  waves 
stand  out  clearly.  The  first  began  abruptly  in  1912  and  lasted  through  1914. 
The  second  wave,  starting  in  1915  with  26  cases  and  4  deaths,  reached  its 
peak  in  1916  with  206  cases  and  70  deaths,  and  subsided  in  1917  with  2 
cases  and  no  deaths.  The  third  wave,  much  less  severe  than  the  second,  but 

Table  97. — Distribution  of  reported  cases  and  deaths  of  poliomyelitis ,  according  to 

months,  from  1915  to  1920,  inclusive. 


C  =  cases.  D  =  death. 


Month. 

1915 

1916 

1917 

1918 

1919 

1920 

Total. 

C 

D 

C 

D 

C 

D 

C 

D 

C 

D 

C 

D 

O 

D 

Jan . 

3 

0 

3 

0 

Feb . 

1 

1 

1 

1 

Mar . 

2 

2 

1 

1 

3 

3 

Apr . 

0 

0 

Mav  . 

1 

1 

1 

1 

June  . 

1 

1 

8 

1 

2 

1 

3 

2 

14 

5 

July  . 

11 

2 

3 

1 

2 

0 

11 

0 

9 

2 

1 

0 

37 

5 

Aug . 

13 

0 

37 

16 

•  •  • 

•  •  • 

7 

2 

27 

10 

2 

0 

86 

28 

Sept . 

1 

1 

71 

24 

•  •  • 

•  •  • 

8 

1 

20 

8 

3 

0 

103 

34 

Oct . 

74 

21 

3 

0 

16 

5 

1 

1 

94 

27 

Nov . 

17 

4 

7 

1 

1 

o 

25 

5 

Dec . 

2 

2 

1 

0 

3 

2 

Total  . 

26 

4 

206 

70 

2 

0 

38 

5 

83 

28 

15 

4 

370 

111 

more  serious  than  the  first,  began  in  1918  with  38  cases  and  5  deaths  and 
attained  its  peak  the  following  year  with  83  cases  and  28  deaths.  With  15  cases 
and  4  deaths  in  1920,  this  wave  had  not  reached  its  ebb.  It  will  be  noted  that, 
as  a  rule,  case-fatality  rate  was  highest  in  the  years  of  greatest  incidence.  It 
would  appear,  therefore,  that  the  invasive  and  the  lethal  capacities  of  the 
disease  have  varied  together. 

The  monthly  distribution  of  reported  cases  and  deaths  for  1915  to  1920 
inclusive  is  given  in  table  97.  The  influence  of  season  upon  the  incidence  of 
the  disease  is  striking.  Cases  occurred  in  January,  February,  and  May  in  but 
one  year  each,  and  in  December  and  March  in  only  two  years.  No  cases  occurred 
in  April.  On  the  other  hand,  cases  were  reported  in  June  in  4  of  6  years.  But 
22,  or  6  per  cent,  of  a  total  of  370  cases  were  reported  in  the  first  5  months  of 
the  calendar  year.  For  the  remaining  months  of  the  year  the  distribution  of 
reported  cases  was,  in  percentages  of  the  total  number,  July,  10;  August,  23; 
September,  28;  October,  25;  November,  7;  and  December,  1.  The  peak  did  not 


430  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

always  fall  in  September,  for  in  the  3  years  of  greatest  incidence  it  occurred  in 
July,  August,  or  October.  A  rise  in  the  number  of  cases  in  August  over  July 
marked  a  severer  season  than  usual,  but  even  then,  as  in  1919,  this  occurrence  did 
not  necessarily  presage  a  continued  rise  during  September  and  October.  Sep¬ 
tember,  then,  is  the  critical  month.  The  occurrence  or  non-occurrence  of  cases 
in  the  early  months  of  the  year  is  without  significance  for  predicting  a  heavy 
or  a  light  visitation  in  the  succeeding  months  of  a  particular  year.  Nor  is  the 
occurrence  of  cases  in  the  early  months  necessarily  associated  with  the  pres¬ 
ence  of  recognized  cases  in  the  city  during  November  and  December  of  the 
previous  year. 

With  the  high  average  fatality  among  recognized  cases,  30  per  cent  of  the 
total  number  reported  in  the  6  years  1915-1920,  it  is  not  surprising  that  the 
distribution  of  deaths  by  months  bears  a  close  relation  to  that  of  reported 


Table  98. — Influence  of  age  upon  incidence  and  fatality  of  poliomyelitis  in  1916. 


Age-period. 

Morbidity. 

Mortality 

Percentage  of 
case  fatality 
within  age 
groups. 

Number  of 
cases. 

Percentage  of 
total  cases. 

Number  of 
deaths. 

Percentage  of 
total  deaths. 

0  to  1  year . 

37 

17.56 

13 

16.17 

35.14 

1  to  2  years. . . . 

43 

20.98 

16 

23.53 

37.20 

2  to  3  years- . . . 

53 

25.86 

16 

23.53 

30.19 

3  to  4  years. . . . 

26 

12.69 

5 

7.35 

19.23 

4  to  5  years. . . . 

16 

7.80 

5 

7.35 

31.25 

5  to  6  years. . . . 

9 

4.39 

3 

4.42 

33.33 

6  to  7  years. . . . 

5 

2.44 

2 

2.94 

40.00 

7  to  8  years. . . . 

3 

1.46 

3 

4.42 

100.00 

8  to  9  years. . . . 

3 

1.46 

2 

2.94 

66.66 

9  to  10  years. . . . 

3 

1.46 

1 

1.47 

33.33 

10  to  15  years. . . . 

3 

1.46 

2 

2.94 

66.66 

15  to  20  years. . . . 

3 

1.46 

1 

1.47 

33.33 

20  to  25  years. . . . 

2 

0.98 

1 

1.47 

50.00 

Total  . 

206 

70 

33.98 

cases.  It  is  worthy  of  note  that  the  case-fatality  rates  among  the  scattered 
cases  of  the  winter  and  spring  months  is  higher  than  among  those  occurring 
in  the  definite  outbreaks  of  the  summer  and  fall  months. 

On  account  of  the  unusual  precautions  taken  to  secure  exactness  of  diag¬ 
nosis,  the  data  in  regard  to  the  influence  of  age,  sex,  and  race  upon  morbidity 
and  mortality  in  the  outbreak  of  1916  are  of  special  importance.  The  distri¬ 
bution  of  cases  and  deaths  according  to  the  age  of  those  affected  is  shown  in 
table  98.  Over  77  per  cent  of  the  cases  and  71  per  cent  of  the  deaths  occurred  in 
children  under  4  years  of  age.  Among  these,  the  incidence  was  greatest  in  the 
third  year,  while  the  mortality  was  heaviest  in  the  second  year  of  life.  The 
fourth  year  of  life  was  marked  by  lightness  of  incidence  and  fatality.  In  indi¬ 
viduals  over  the  fifth  year  of  age  incidence  was  light,  but  fatality  was  uniformly 
high.  While  the  case  fatality  for  the  whole  group  was  34  per  cent,  under  the 
fourth  year  it  was  31.44  per  cent,  and  over  this  age  42.55  per  cent.  Both  mor¬ 
bidity  and  mortality  in  negroes  were  double  those  in  whites  and  somewhat 


FEBRILE  DISEASES 


431 


greater  in  males  than  in  females  in  both  races  (table  99).  The  percentage  of 
case-fatality  was,  however,  somewhat  lower  in  negroes  than  in  whites.  It  was 
considerably  less  in  females  than  in  males  and  in  white  females  than  in  white 
males.  The  fatality-rates  were  identical  for  the  two  sexes  in  negroes. 

Restrictive  measures  on  patients  and  contacts,  with  hospitalization  of  a 
considerable  number  of  cases,  were  instituted  from  first  appearance  of  the 
diseases  in  1916,  but  there  is  little  evidence  of  a  convincing  nature  that  either 
these  measures  or  the  inadequate  quarantine  attempted  on  children  from  New 
York  and  other  cities  where  the  disease  was  prevalent  interfered  seriously 
with  the  spread  of  the  affection.  At  the  very  height  of  the  outbreak,  the  inci¬ 
dence  of  the  disease  dropped  abruptly  about  the  middle  of  October,  imme¬ 
diately  after  a  decided  fall  in  the  temperature  lasting  several  days,  and 
subsequent  to  this,  but  few  cases  were  reported. 


Table  99. — Rate  per  100,000  living  inhabitants  of  morbidity  and 
mortality  and  percentage  of  case  fatality,  according  to  color 
and  sex,  for  poliomyelitis  for  1916. 


• 

Morbidity. 

Mortality. 

Percent¬ 

age 

case 

fatality. 

Cases. 

Rate. 

Deaths. 

Rate. 

Total  . 

206 

34 

70 

12 

34 

Total  male  . 

107 

36 

39 

13 

36 

Total  female  .... 

99 

32 

31 

10 

31 

Total  white  . 

149 

29 

51 

10 

34 

White  males  .... 

80 

32 

30 

12 

38 

White  females  . . . 

69 

27 

21 

8 

30 

Total  colored  .... 

57 

59 

19 

20 

33 

Colored  males  . . . 

27 

61 

9 

20 

33 

Colored  females  . . 

30 

57 

10 

19 

33 

TETANUS  AND  ERYSIPELAS. 

Tetanus  and  erysipelas  are  the  only  affections  associated  directly  or  indi¬ 
rectly  with  wound  infection  that  can  be  traced  consistently  in  the  mortality 
tables  from  the  early  years  of  the  nineteenth  century.  Puerperal  fever,  which 
will  be  considered  under  child-birth,  may  be  followed  as  a  separate  entity 
only  since  1875.  Through  much  of  the  period  a  considerable  number  of 
deaths  have  been  attributed  to  abcess  of  various  organs.  In  the  seventies, 
eighties,  and  early  nineties  of  the  last  century  a  significant  proportion  of 
deaths  (66  in  1889,  for  instance)  was  attributed  to  peritonitis,  many  of 
which  were  doubtless  secondary  to  appendicitis,  puerperal  infection,  and  to 
operations  on  the  abdominal  organs.  The  numerous  deaths  that  must  have 
been  caused  by  septicaemia,  and  pyaemia  following  wound  infection  were  classi¬ 
fied  under  other  headings. 

Under  the  heading  lockjaw  for  the  most  part  until  1850,  although  in  some 
years  classed  as  tetanus,  deaths  from  this  disease  were  recorded  in  each  year, 
except  1862,  from  1812  to  1920  (table  91).  From  1875  to  1898,  inclusive,  a 
considerable  number  of  deaths  were  credited  annually  to  trismus  nascentium. 
Since  the  disappearance  of  the  latter  rubric  with  the  adoption  of  the  inter- 


432  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


national  classification  of  the  causes  of  death  in  1899,  deaths  from  this  form 
of  the  disease  have  been  classified  under  tetanus.  Previously  to  1875,  deaths 
from  infantile  tetanus  were  probably  classified  under  convulsions.  Judging 
from  the  number  of  deaths  attributed  to  trismus  nascentium  and  to  tetanus, 
respectively  (for  example,  44  to  11  in  1876;  46  to  16  in  1880;  45  to  12  in 
1896),  infantile  tetanus  must  have  been  an  important  cause  of  death  before 
1875.  Before  the  latter  date,  therefore,  the  rates  calculated  from  the  official 
figures  for  tetanus  must  be  far  below  actual  occurrence.  The  fluctuations  in 
the  rates  for  tetanus  from  year  to  year,  both  before  and  after  1875,  do  not  in 
general  vary  widely.  From  table  100,  in  which  the  rates  for  tetanus  (includ- 


Table  100. — Average  rate  oj  death,  per  100,000  living  inhabitants,  by  5-year  periods,  jor 
tetanus  and  erysipelas,  from  1812  to  1920,  inclusive. 


Periods. 

Tetanus. 

Erysipelas. 

Periods. 

Tetanus. 

Erysipelas. 

Periods. 

Tetanus. 

Erysipelas. 

1812-15  ... 

4 

2 

1851-55  ... 

2 

9 

1891-95  ... 

11 

5 

1816-20  ... 

5 

6 

1856-60  ... 

2 

8 

1896-1900  . 

6 

5 

1821-25  ... 

4 

1 

1861-65  ... 

2 

11 

1901-05  ... 

4 

5 

1826-30  ... 

3 

•  • 

1866-70  ... 

3 

7 

1906-10  ... 

4 

4 

1831-35  ... 

4 

2 

1871-75  ... 

7 

14 

1911-15  ... 

3 

4 

1836-40  ... 

2 

1 

1876-80  ... 

16 

9 

1916-20  ... 

1 

4 

1841-45  ... 

2 

2 

1881-85  ... 

16 

10 

1846-50  ... 

3 

11 

1886-90  ... 

13 

8 

ing  trismus  nascentium)  as  averaged  for  quinquennial  periods  are  presented, 
it  will  be  noted  that  after  rising  from  4  for  the  period  1812-1815  to  5 
for  1816-1820,  the  rate  fell  during  the  succeeding  10  years,  and  for  the  5 
years  ending  in  1830  was  only  3.  After  rising  again  to  4  in  1831-1835,  the 
rate  declined  to  2  during  the  10  years  1836-1845.  Between  1846  and  1870 
the  rate  fluctuated  between  2  and  3.  The  appearance  of  trismus  nascentium 
in  statistical  nosology  was  reflected  by  an  abrupt  rise  in  the  rates  to  new  high 
levels — 7  in  1871-1875,  and  16  in  1876-1885.  During  the  next  15  years  the 
rates  sharply  declined.  During  the  10  years  1901-1910,  the  rates  stood  at  4, 
between  1911  and  1915  they  fell  to  3,  and  during  the  last  5-year  period  to  1. 

While  the  spectacular  rise  in  the  rates  for  tetanus  after  1875  was  due  to  a 
very  marked  degree  to  changes  in  the  custom  of  classification  of  deaths,  and 
the  rates  before  this  date  must  be  regarded  as  much  too  low,  the  subsequent 
course  of  the  curve  may  be  taken  as  indicating  with  a  fair  degree  of  accuracy 
the  force  of  mortality  from  tetanus.  There  can  be  no  doubt  that  infantile 
tetanus  was  of  common  occurrence  during  this  period.  This  question  was 
investigated  in  the  late  nineties  by  Dr.  C.  Hampson  Jones,  who  found  the 
disease  especially  common  in  the  practice  of  midwives.  In  the  practice  of 
one  midwife  he  was  able  to  trace  14  deaths  from  trismus  nascentium.  There 
seems  little  doubt  that  the  marked  fall  in  the  mortality-rate  from  tetanus 
since  1895  has  been  due  in  large  measure  to  improvement  in  midwifery,  the 
gradual  decrease  of  Fourth  of  July  accidents  from  fire-crackers  and  the  like, 


FEBRILE  DISEASES 


433 


the  practice  of  antiseptic  and  aseptic  surgery,  and,  of  late  years,  the  use  of 
prophylactic  injections  of  tetanus  antitoxin  in  connection  with  wounds  suit¬ 
able  for  the  development  of  B.  tetani.  Since  1917  tetanus  antitoxin  has  been 
furnished  free  of  charge  to  those  unable  to  purchase  it  for  both  prophylactic 
and  curative  treatment. 

With  the  exception  of  a  few  years  (1819-1821,  1824-1830,  1836-1837, 
1840-1841,  and  1844),  erysipelas  has  been  credited  with  deaths  in  each  year 
from  1814  to  1920,  inclusive.  The  rates,  as  averaged  for  quinquennial  periods, 
are  given  in  table  100.  It  would  appear  from  the  official  figures  that  the  disease 
was  either  not  very  prevalent,  or  at  least  was  characterized  by  a  low  mortality 
until  after  1845.  The  number  of  deaths  rose  abruptly  from  4  in  1845  to  14  in  the 
following  year,  and  it  would  appear  that  at  this  period  there  began  an  epi¬ 
demic  wave  that  lasted  until  well  after  1890.  The  rate  was  no  higher  during 
the  Civil  War  period  than  it  was  between  1846-1850.  T.  H.  Buckler  described 
as  unusual  occurrences  at  the  city  almshouse  and  infirmary  during  the  latter 
period  a  series  of  very  fatal  epidemics  of  this  disease.  Rising  from  2  for  the 
previous  quinquennium  to  11  between  1846-1850,  the  averaged  rate  for 
erysipelas  varied  little  from  this  level  until  after  1865.  Falling  during  the  next 
5  years  to  7,  and  rebounding  to  14  between  1871  and  1875,  the  rate  main¬ 
tained  a  level  about  9  for  15  years,  and  held  constant  at  5  between  1891  and 
1905  and  at  4  from  1906  to  1920. 

Of  the  various  general  diseases  associated  most  commonly  and  most  surely 
with  secondary  infection  with  streptococcus,  the  causal  agent  of  erysipelas, 
scarlet  fever  is  perhaps  the  most  prominent,  and  comparison  of  their  course 
for  a  possible  correlation  between  their  periods  of  greatest  mortality  is  of  some 
importance.  When  this  is  done  (tables  34  and  91),  it  is  found  that  the  ascent 
to  high  levels  in  the  rate  for  erysipelas  did  not  begin  until  15  years  after 
scarlet  fever  had  attained  a  high  point,  that  the  rate  for  the  latter  had  fallen 
from  its  high  level  well  before  that  for  the  former  had  reached  its  peak,  and 
that  the  final  decline  in  the  rate  for  scarlet  fever  anticipated  the  fall  in  the 
rate  for  erysipelas.  It  would  appear,  therefore,  that  if  comparison  of  the 
course  of  their  death-rates  indicates  anything  in  this  connection,  it  is  that  the 
streptococcus  mixed  infection  in  connection  with  scarlet  fever  may  have  been 
a  determining  factor  in  the  initial  rise  in  the  rate  for  erysipelas  and  the  subse¬ 
quent  course  of  that  disease.  The  possible  influence  of  scarlet  fever  and 
erysipelas  upon  the  prevalence  of  puerpural  fever  will  be  discussed  later. 

Although  erysipelas  has  long  been  a  reportable  disease,  it  may  not  be  claimed 
that  attempts  at  its  control  by  administrative  activity  of  the  health  department 
have  materially  influenced  its  course.  The  admission  of  known  cases  to  general 
hospitals  for  treatment  had  been  debarred  by  fear  of  its  spread  long  before  the 
practice  was  forbidden.  Oversight  of  routine  cases  in  homes  has  not  been  prac¬ 
ticed.  Changes  in  the  course  of  the  disease  have,  then,  been  due  to  modifica¬ 
tion  in  the  infecting  agent  and  its  hosts  on  the  one  hand  and  of  treatment  on 
the  other. 

APPENDICITIS. 

It  is  only  since  1899  that  this  cause  of  death  can  be  traced  with  any  accu¬ 
racy.  Previous  to  this  date,  with  the  exception  of  a  few  deaths  ascribed  to 
typhilitis  after  1881  and  to  appendicitis  after  1895,  deaths  from  this  cause 


434  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

were  probably  classified  chiefly  under  peritonitis  and  inflammation  of  the 
bowels.  The  mortality  data  as  annually  recorded  for  typhlitis  or  appendicitis 
since  1881  are  presented  in  table  128.  It  will  be  observed  that  from  1890, 
when  interest  in  this  affection  appears  to  have  begun,  the  annual  rate  rose 
rather  steadily  to  10  in  1899.  Since  this  date  the  annual  rate  has  fluctuated 
between  10  and  16.  But  this  wide  difference  in  the  extremes  does  not  occur 
as  between  the  first  and  last  years  of  this  period,  but  rather  over  short  series 
of  years,  marking  alternate  waves  of  gradual  ascent  and  decline. 

When  the  rates  are  averaged  for  5-year  periods,  from  1901  to  1920  (table 
131)  it  is  found  that  the  average  mortality  has  varied  but  little,  and  between 
the  first  and  the  last  of  these  quinquennia  there  was  but  a  slight  increase.  It 
wrould  appear,  therefore,  that  in  the  mortality  from  this  affection  in  the  period 
under  consideration  there  is  a  definite  tendency  to  periodic  exacerbations  and 
declines,  which,  however,  are  so  distributed  that  over  a  term  of  years  its  lethal 
force  is  equalized.  As  this  marks  the  period  in  which  the  diagnosis  and  surgical 
treatment  and  the  statistical  classification  of  deaths  of  this  affection  have  been 
perfected  and  stabilized,  the  recorded  mortality-rates  may  be  taken  as  reflect¬ 
ing  the  average  annual  risk  in  this  population  of  unpreventable  death  from 
tills  cause.  In  other  words,  since  1901  the  risk  of  the  occurrence  of  appendicitis 
in  degree  of  severity  beyond  the  sphere  of  natural  resistance  and  of  remedial 
agencies  has  been  in  the  ratio  of  about  12  in  100,000,  or  1  in  8,333,  for  each 
inhabitant. 


PART  VI.— VARIOUS  CHRONIC  ORGANIC  DISEASES. 

Chapter  XIII. — Tumors. 

(Tables  101  to  109,  graphs  27  to  29.) 

With  the  exception  of  1815  and  1823,  deaths  from  cancer  have  been  recorded 
every  year  since  1813,  but  not  until  1875  were  they  classified  by  organs  af¬ 
fected.  In  that  year  deaths  from  this  affection  were  classified  under  cancer — 
diffused,  breast,  liver,  face,  rectum,  uterus,  stomach,  neck,  leg,  brain,  and 
pylorus.  In  1878  there  were  added,  cancer  of  the  tongue,  testicle,  intestines, 
oesophagus,  trachea,  mouth,  eye,  mesentery,  arm,  omentum,  elbow,  and  spine. 
Between  this  date  and  the  adoption  of  the  international  system  of  classification 
in  1899,  the  statistical  rubrics  were  expanded  to  include  each  organ  or  part 
certified  in  any  particular  year  as  the  seat  of  fatal  cancer.  Since  1905,  these 
have  been  contracted  to  conform  to  the  limits  of  the  international  system. 

Though  the  rubric  tumor  appeared  in  the  statistical  records  in  1821,  1822, 
1829,  and  1830,  it  was  not  until  1833  that  it  became  permanently  established. 
Not  until  1875  were  the  deaths  classified  by  organs  affected,  i.  e.,  ovary,  abdo¬ 
men,  uterus,  rectum,  and  face.  As  with  cancer,  the  statistical  nosology  was 
expanded  to  include  such  other  organs,  but  usually  only  the  brain,  to  which 
deaths  from  tumors  were  ascribed. 

That  not  all  deaths  due  to  cancer  were  properly  assigned  in  the  earlier 
years  is  clear  from  the  fact  that  in  1878,  to  cite  one  example,  there  were 
ascribed  to  stricture  of  the  rectum  1  death,  of  the  cardiac  end  of  the  stomach 
6  deaths,  and  of  the  intestine  3  deaths.  In  1875,  1  death  was  attributed  to 
tumor  of  the  rectum  and  another  to  tumor  of  the  face — very  unlikely  seats 
for  fatal  benign  tumors.  Since  1910,  under  the  classification  rules  of  the 
Bureau  of  the  Census,  tumor  of  the  brain,  which  from  this  date  has  been 
recognized  with  greater  frequency  than  before  through  the  development  of 
operative  procedures  for  its  relief,  has  been  hidden  under  “  other  diseases  of 
the  nervous  system.”  Because  a  considerable  proportion  of  brain  tumors  are 
malignant,  this  practice  has  affected  the  rates  for  both  cancer  and  tumor. 
After  1899,  deaths  ascribed  to  tumor,  with  a  few  relatively  unimportant 
exceptions,  have  been  those  thought  to  have  been  due  to  benign  tumors  of  the 
female  generative  organs — the  ovary  and  the  uterus.  Therefore,  before  this 
date  and  particularly  in  the  earlier  years,  no  sharp  distinction  was  drawn 
between  cancer  and  tumor,  and  the  latter  rubric  by  no  means  always  meant 
benign  tumor,  as  opposed  to  cancer.  It  is  likely,  however,  that  the  old  rubric, 
cancer,  included  most  tumors  now  classified  under  the  general  heading  of 
cancer  and  other  malignant  tumors. 

It  would  serve  no  useful  purpose  to  trace  here  the  history  of  the  various 
conceptions  of  tumors  and  their  classification.  It  will  suffice  to  point  out  that, 
before  the  beginning  of  the  period  under  review,  it  was  established  that  tumors 
are  non-infiammatory  or  autochthonous  new  growths,  and  that  benign  tumors 

435 


436  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

cause  death  mainly  by  mechanical  pressure  resulting  from  position  and  size, 
and  by  such  accidents  as  hemorrhage  and  torsion,  while  cancerous  or  malig¬ 
nant  growths  tend  to  spread  locally  and  distantly  and,  in  some  ways  even  yet 
unknown,  to  exert,  as  a  rule,  specific  deleterious  effects  upon  the  body  as  a 
whole,  resulting  in  anaemia,  prostration,  and  finally  death. 

In  table  101  the  data  for  cancer  and  tumor  are  presented  separately  and 
combined.  It  will  be  noted  (graph  27)  that  the  crude  mortality-rates  for 
tumors  as  a  whole  were  relatively  low  until  after  1870.  With  considerable 
fluctuations,  the  annual  rates  ascended  from  2  in  1813  to  15  in  1821  and  to 
20  in  1846.  By  1850  the  rate  had  fallen  to  9,  and  it  was  not  until  1865  that 
the  level  of  1846  was  again  attained.  After  rising  to  27  in  1868  and  falling 
to  20  by  1870,  the  rate  rose  steadily,  with  but  few  recessions,  to  117  in  1920. 
Through  most  of  the  period  between  1835  and  1920,  the  rates  for  tumor  alone 
show  considerable  annual  fluctuations.  Always  inconsiderable,  the  rates  ex¬ 
ceeded  10  in  but  one  year.  These  rates  rose  decidedly  between  1865  and  1877, 
and  between  the  latter  year  and  1905  there  was  on  the  whole  but  little  change. 
The  rates  fell  appreciably  between  1906  and  1915,  but  from  1916  to  1920  they 
approached  their  former  higher  level. 

During  the  entire  period  under  review,  the  curve  of  the  rates  for  cancer  alone 
has  followed  closely  that  of  the  combined  rate,  and  the  predominant  impor¬ 
tance  of  this  rubric  has  determined  the  shape  of  the  curve  for  the  combined 
rate.  The  rates  for  cancer,  with  considerable  fluctuations,  varied  from  2  in 
1813  to  11  in  1835.  After  fluctuating  between  5  and  15  from  1835  to  1865, 
the  annual  rate  reached  20  for  the  first  time  in  1867.  Having  reached  51  in 
1880,  after  several  advances  and  declines,  the  rate  rose,  with  relatively  minor 
recessions,  to  113  in  1920. 

When  the  irregularities  due  to  minor  annual  fluctuations  are  smoothed  by 
averaging  the  rates  for  5-year  periods  (table  102  and  graph  28),  a  sharply 
cut  picture  of  the  course  of  mortality  of  these  affections  is  presented.  The  total 
rate  rose  from  4  for  the  period  1812  to  1815  to  8  for  the  5-year  period  end¬ 
ing  in  1820.  Following  a  slight  recession  during  the  next  5  years,  the  rates 
rose  to  9  between  1826  and  1830,  and  fell  to  8  for  the  period  ending  in  1835. 
The  rates  remained  practically  stationary  at  11  between  1836  and  1845  and 
at  13  between  1846  and  1860.  The  slight  increase  to  16  for  the  succeeding  5 
years  was  followed  by  a  sharp  rise  to  23  for  the  period  between  1866  and  1870. 
From  this  date,  but  for  a  slight  recession  for  the  5  years  1881-1885,  the  rates 
rose  steadily  between  1866  and  1920,  and  reached  111  for  the  period  1916- 
1920.  The  averaged  rates  for  tumor  which  never  attained  4  before  the  5-year 
period  ending  in  1870,  gradually  rose  during  the  next  10  years  and  averaged 
7  between  1876  and  1880.  This  gain  was  more  than  lost  during  the  next  5 
years,  but  after  1885  the  course  of  the  rates  turned  and  rose  steadily  to  8  for 
the  5  years  ending  in  1905.  Falling  during  the  next  10  years  to  the  level  of 
1870,  for  the  period  between  1911  and  1915,  the  average  rate  for  the  5  years 
ending  in  1920  was  5.  For  cancer,  the  averaged  rates  were  4  between  1812 
and  1815,  and  8  during  the  next  5  years.  After  receding  to  4  between  1821 
and  1825,  and  rising  to  9  between  1826  and  1830,  the  rates  remained  prac¬ 
tically  stationary  between  1831  and  1850.  Rising  but  slightly  to  11  between 
1851  and  1860  they  ascended  more  rapidly  during  the  next  15  years  to  26 
for  the  period  ending  in  1875.  Between  1876  and  1885  the  rates  averaged 


VARIOUS  CHRONIC  ORGANIC  DISEASES 


437 


47,  and  from  1886  to  1920  the  rates  rose  to  106.  It  will  be  noted  that  after 
1895  the  rate  increased  by  from  7  to  10  for  each  5-year  period. 

Data  are  available  for  calculating  the  effect  of  color  and  sex  upon  the  crude 
rates  for  cancer  for  the  21-year  period  1900-1920.  These  are  set  forth  in 
table  103.  In  this  period  the  rates  for  whites  rose  from  64  to  116  and  for 
negroes  from  55  to  95.  For  sex,  the  increases  in  the  rates  were :  White,  males 
from  46  to  108,  females  from  81  to  124;  negro,  males  from  23  to  69,  females 
from  81  to  119.  The  course  of  the  rates  for  both  sexes  in  whites  was  much 
smoother  than  in  negroes.  The  annual  fluctuations  in  the  rates  for  negro 
males  were  particularly  marked.  There  were  on  the  whole  no  great  differences 
between  the  rates  for  females  of  the  two  races.  In  few  years,  however,  do  the 
rates  for  negro  males  approach  those  for  white  males.  In  no  one  of  the  four 
groups  did  the  rates  fail  to  increase  considerably  during  the  period. 

The  influence  of  age  upon  death-rates  for  cancer  in  1911  and  1920  is  shown 
in  table  104.  The  whole  of  the  mortality  below  the  thirtieth  year  of  life 
occurred  in  the  white  race,  in  which  the  rate  below  the  tenth  year  was  2, 
between  the  tenth  and  nineteenth  years  only  3,  and  between  the  twentieth 
and  twenty-ninth  years  only  25.  Under  the  tenth  year  nearly  all  the  deaths 
occurred  in  the  first  year  of  life,  when  the  rate  was  11.  The  high  fatality  during 
the  first  year  of  life  was  doubtless  due  to  congenital  tumors,  for  the  most  part 
teratoid.  The  malignant  tumors  fatal  for  the  ages  10  to  30  were  probably 
for  the  most  part  sarcomata.  Following  the  rates  for  the  whole  population 
from  the  thirtieth  year,  it  will  be  noted  that  they  rose  from  12  for  the  third 
decade  to  28  for  the  fourth,  to  114  for  the  fifth,  to  299  for  the  sixth,  to  464 
for  the  seventh,  to  603  for  the  eighth,  and  to  1,123  for  80  years  and  over. 
The  rates  for  the  white  population  were  nearly  double  those  for  the  negro  in 
the  third  decade,  but  after  this  period  they  conformed  closely  to  those  for 
the  whole  population  during  the  remainder  of  the  life-span.  The  rate  for  the 
negro,  which  somewhat  exceeded  the  white  and  the  total  rates  in  the  fifth 
decade,  fell  somewhat  below  those  in  the  sixth  and  seventh  decades,  and  drop¬ 
ping  decidedly  from  381  to  201  between  the  seventh  and  eighth  decades,  rose 
to  676  for  80  years  and  over.  From  birth  to  the  fortieth  year  and  from  the 
sixtieth  year  to  the  end  of  life,  therefore,  the  rates  for  whites  were  decidedly 
higher  than  those  for  negroes. 

In  comparing  the  two  sexes,  all  the  deaths  during  the  first  year  were  in 
white  females,  and  all  those  between  the  first  and  the  ninth  year  were  in 
white  males.  The  rates  for  whites  of  both  sexes  under  the  tenth  year  were 
the  same.  During  the  second  decade,  the  rate  for  females  failed  to  rise,  while 
those  for  males  rose  continuously  to  the  end  of  life.  The  rate  for  white 
females  crossed  that  for  white  males  in  the  third  decade  and,  but  for  a  reces¬ 
sion  in  the  eighth  decade,  remained  decidedly  higher  throughout  life.  The 
rates  for  negro  males,  which  were  11  for  the  third  decade  and  13  for  the 
fourth,  rose  to  71  for  the  fifth  and  to  203  for  the  sixth.  Falling  to  a  rate  of 
152  for  the  seventh  decade,  cancer  caused  no  deaths  in  negro  males  after  the 
seventieth  year  of  age.  Starting  with  a  rate  of  17  for  the  third  decade  and 
rising  to  the  level  of  the  rates  for  white  females  for  the  fourth  decade,  the 
rate  for  negro  females  was  226  in  the  fifth  decade.  Again  approaching  the 
rate  for  female  whites  in  the  sixth  and  seventh  decades,  the  negro  female 
rates  fell  decidedly  from  574  in  the  seventh  to  337  in  the  eighth  decade.  For 


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^■H  rH  r— <  p-H  rH  p-H  r-H  r-H  r-H  p-H  r-H  r-H  rH  r-H  r-H  r-H  r-H  r-H  r-H  r-H  rH  rH  rH  r-H  rH  rH  r-H  r-H  r-H  rH  rH  rH  r-H  rH  rH  r-H  rH  rH  r-H  r—H  rH  r-H  r-H  rH  r-H  rH  r-H 

(439) 


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Tumors. 

Percentage 

of  total 

deaths 

from 

all  causes- 

cococ^eocoeoTtiTti^rt<coTtiT*iTfiioio*o^iooioio*oco<c>o<ocDT^r^oo 

• 

Total. 

PS 

r-ifH«)(NtHO}tHO^(0!»OOOOailN©OOCDC300©NlO«NH®tHOON 

f-!OIO®©ffitHt't'tH®NNNOa)QOOOOOCJ050SOCCHOOOH 

rH  rH  rH  rH  r-H  rH  rH  rH 

Q 

NNC3(N(NmO>(N©oO«0«)CROrtOCO^(NOi^NO'#lO^COCIONO 

OaiOMHMCO^OfH'^OOHOOOQOJOONlOWCCWHTKtHOlOtHCO 

W(N(NM««ncOCO««^'^^'^'^V<^-^rtU(3»0‘OCDCDCOCOCOCOtHOO 

Tumor. 

PS 

r^tH.cotH.coTjiooutir^ooU3oo»r303t^ootH'^coTt<io»r3'^'^cococoiocO'^ir5 

Q 

HOffiHOHNffilOoi'ON^aOiHOMlOlNOOOlNNOlOOOOOOHOOCO 

WCONNNINCCKNCOnM'^W'^'^'^'^INWlNMNCSNHrHCOMMWW 

Cancer, 

PS 

■<HONU3INT)(C5lOfHooMO^O'fH(NWO©(NHnHOTtUOlOCOMlM 

®©lQlOffl©ffi®©o©tHMHOOOOOOMOOtHOaaiOOOOOOOH 

rH  l-H  l-H  i-H  r-H  rH  rH  rH 

a 

fflNCOHONNOHoiOOOO'l'OONOnOOOOWOOlfJNfflONON 

fHCCOlOCOOCOiHCOMHlOOOtHlOCOlON^lOIMIN^CJCRlNMTttW^IN 

<N<N<M03C^CCOOOOCOcoWC'OOOC<0''*''*l'<*'«4<-'tf-<*U01CO»COlCOlCDCOCOCOCOt'rOO 

Cardio-vascular  renal  diseases. 

Percentage 

of 

total  deaths 
from 

all  causes. 

N(NNinCO®lQ®10rHNrH03000HHNlNWlCi[HNNO>05Hf0030 

hhhhhhhhhhHhhmMNNNNNNMNNNMNCONNM 

Total. 

cs 

^«(N®N100«HoO^WC3iJlT»(OM<HTjH^©tHNNWHTjtNlHHN 

NOO©0®^(NHIN^lOlO©COHOH«HO®THNlOtHK)H©05ffl»0 

NNNCOWCOCOCOMcoCOCOCOCO^^TjHiHTjiTH^if^-tTiHTltlOlOIO^iH 

a 

©M^CONNNMCOHlOCOHlOOlNNHOO^^NffiHWJNNlOfflO 

OOlOHC3HNMNOOTl<ffiHNINH®©CCl(NCO®OOOOC5(NCJHtHCC(NW3 

H^«coNffiioinioiHtHooc»o(NHiNn«(N®iON®co!)OTHTji®con 

HHHrtHHHHHHHHHNNINNNNMNlN(NIN(N<NCOnWnCO 

Dropsy. 

PS 

COOJ10N®OONCOlO^«NfOM«NHHNH . 

a 

00«(NlNN®lOWO©f'O^MNOtH'<JiaCH . 

N«NCCNCC«HINHHrtHHHH  . 

Nephri¬ 

tis. 

PS 

OlOOCSN0inaN'^C5®n(M'<J<00®ffiQ^lC05H®®®tH'^©0!>0) 
NtHCJC5U3HHHHMeJMK'ltlO>0®®®®a)®C5tHlO®®OOOOIO'^ 
rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  r-H  rH 

Q 

'MHOOfflOlHCOOOOOlOH^MacOIOrofflOrflOOOOOMfflCONH 

OW01C®IOiJtTttU3®10lOC!»OINU30W^(N10NH'iHlN©HIM'^COO) 

COW^'HWlOIOlOlOCOOCONOOOOCJOJOOOOHOOiroOHHHO 

rH  rH  r-H  rH  rH  rH  rH  rH 

Aneurism 

and 

arterio¬ 

sclerosis. 

PS 

MNW(N(NCON'!tt®N^ai(NN®(NH©H(»H®nH(N®OCONO® 

HHH(MiM(M(M(NH(MM«CClMICOlON«n(NMH 

Q 

!OH«OOCOOOHCOH©(N'#'#NMNN(»©t'^(NHffiOnffl^W3 
rH  rH  rH  rH  rH  rH  rH  CSI  CO  CO  t-“  03  rH  rH  ICO  rH  r-H  O  rH  ICO  t*-*  O  ICO  CO  rH  ICO  00  O  CO  ^  rH 

hhhhhhhhhinnhcchhcihhh 

Diseases  of  cerebral  blood 
vessels. 

Total. 

PS 

(NffilOlOOCOCOOOOOHIN^^OTjUOHNOOINOHOOOHlOOM 

OONNOOOOQNNt't'OOOONNNCOONOlONNt^OlOOOHlNCOHH 

rH  rH  rH  rH  rH  rH 

a 

©C3»COC003l>-OOOOTtlC3i-HCOT*rHlCOt^r'-.COCOC©<MCOt^OO»C3lC01>.03lCOOOeO 

ico^eooo©mT)(©NcorH(Nooo30Hf>oaNHOHowrHicooconcoN 

coeocococo-^cocococO'^H^coco,^cococoeocoT^H^rt<icoio©rriD-oooooo 

Softening 

of 

the  brain. 

PS 

OCOOOOOCOOIOIO  •COOOCOX^'^IO^COIN^WCOHHHHH  •  H  H  • 
t— H  •  •  • 

Q 

(NOO^OONMOIO  -1— l(NC3©<MTfia3©»rOCOrHC<»OOt^OOCOlCOl003COHtieO 

•^NCOCONTj<M(M  -COiJKN^NNINNHHINHH 

Apoplexy. 

PS 

MMNN^rJ1Nr-i©(NWN©OHaia00i0(NC00300OIC3C0©OiH©C; 

NN©t-000©Nr-I>t^N®NN»0©©©lO©©©03000H(NmHH 

rH  rH  rH  rH  rH  rH 

O 

OOHHO(NlfO(NM^OOO>^^aiH(»NMn©OCOOOCJO(NN®^0 

OWOlO^ffilN^t^lOOOTjiOOOHCONOOaiOOCOOlOOOOINMlM 

COCOCOCOCOCOCOCOCOCOCOCOCOCOCOCOCOCOCO(NCOCOHjHlCO»C3COt'-.t^OOOOOO 

Diseases  of  the  heart. 

Total. 

PS 

CO  ©  ©  CO  t—  CO  UO  CO  03  CO  ©  CO  CO  hji  CO  ^  rH  rH  CO  ICO  ©  ©  CO  03  03  ©  rH  03  00  t>»  © 
rHiHMHHCINHC)HOC)C0'^10©©©10»O00NN©r'00©(N^©00 
rHrHrHrHi-HrHr-HrHr-HrHrHr-HrHrHrHi-Hr-Hi— IHHHHHHHHNNNHH 

Q 

COTHOOOO»COC300lCO<D303©Htf©t^lO»COrHTt<CO©©ICOlM©t^COt^r-HCOt^rH 
OJOCOHrJiOOOI^OCOiJfCOr-iWiHCOCOONNCOCOHCOOCOHOCOOlN 
rfl  ICO  ICO  ICO  ICO  ICO  ICO  ICO  ©  ICO  ©  ©  I"-  00  CO  00  0000000030©©Od^©NCO 

r-H  rH  rH  rH  rH  r-H  rH  rH  r-H 

Organic 

diseases 

of 

the  heart. 

Ph 

©rH©OOMNNnC'©H©H©^NCO^OONHON©OCOOOO©a>0 

OHHOHHHHHH(NHC,3CO'^'^lOlCOTHr*INOfflTj(©l>©HCO>C5N 

rH  rH  r-H  rH  i — IrHr-HrHi — 1  i — 1  i — Ir-HrHrHrHrHr-HrHrHrHrHrHrHr-HrHrHrHCSOIrHr-H 

Q 

W(N©-#©(NH0000NmN«NH^aiMffiTt(00NTj(N©00Hffl(N©O 
©C3H03(NW©^NlOiHOOOiHN©CO©(NCOC^(N'^f^OCOlCOCO»OT)110 
•<tlTj<lC0TtllC0lC0lC0»C0lC0lC0©lC0©t-rr—  t-r00  00  00  00  03  C3C300©OrHC0TtfrH03 

i-H  r-H  r-H  rH  rH  rH  rH 

Angina 

pectoris. 

PS 

NNIOIO^(OOOCOIOO^NOOOOOXOOOOOOJ>C50(NOONhHCOOO 

r-H  r-H  r-H  rH  r-H  rH  r-H  rH 

a 

i-HCSC0r^©©l^.l^Tji©r^r^C0©TtirH(N<N'^O3(M00  00©O3lO©lC0rH(MrH 
COCOCS<N<MCOCOC'303CO(MCOCO'<i<TH'r*l'>^T*lTHTtllc01CO©lCO©'^©©00©t>- 

Year. 

©!-HlMCO'^lO©r^OO©©rH(D3CO-<tl»CO©I^OO©©rH(NCO'^lOCOrrOO©© 
©03©03©G3C3©©©©©©©00©©©©rHrHrHrHrHrHrHi— 1  H  H  W 
oDMCoooooooKooooooaocsoojOffloocaoaffloffioiooooios 

rH  r-H  rH  rH  rH  r-H  rH  rH  r—1  rH  rH  rH  r-H  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH  rH 

(440) 


VARIOUS  CHRONIC  ORGANIC  DISEASES 


441 


Graph  27  (from  table  101).  Annual  crude  mortality  rates  from  tumor 
(cancer  and  other  tumors)  and  from  cardio-vascular-renal  diseases,  from 
1812  to  1920,  inclusive. 


Table  102. — Average  rate  of  death,  per  100,000  Hiring  inhabitants  by  5-year  periods, 
from  cancer,  and  other  tumors,  and  from  senility  and  causes  unknown  in  adults, 
from  1812  to  1920,  inclusive. 


Periods. 

Cancer. 

Tumor. 

Total 

cancer  and 
tumor. 

Senility. 

Causes 

unknown. 

Total 
senility 
and  causes 
unknown. 

1812-15  . 

4 

•  •  • 

4 

145 

•  •  • 

145 

1816-20  . 

8 

•  •  • 

8 

123 

•  •  • 

123 

1821-25  . 

4 

1 

5 

120 

39 

159 

1826-30  . 

9 

•  •  • 

9 

119 

56 

175 

1831-35  . 

7 

1 

8 

126 

30 

156 

1836-40  . 

8 

2 

10 

95 

22 

117 

1841-45  . 

9 

3 

12 

76 

40 

116 

1846-50  . 

10 

3 

13 

96 

74 

170 

1851-55  . 

11 

2 

13 

100 

56 

156 

1856-60  . 

11 

3 

14 

94 

73 

167 

1861-65  . 

14 

2 

16 

85 

63 

148 

1866-70  . 

19 

4 

23 

89 

62 

151 

1871-75  . 

26 

6 

32 

100 

36 

136 

1876-80  . 

47 

7 

54 

72 

4 

76 

1881-85  . 

47 

4 

51 

77 

3 

80 

1886-90  . 

57 

6 

63 

74 

1 

75 

1891-95  . 

59 

6 

65 

80 

80 

1896-1900  . 

66 

7 

73 

65 

65 

1901-05  . 

76 

8 

84 

54 

54 

1906-10  . 

84 

5 

89 

41 

41 

1911-15  . 

97 

4 

102 

28 

28 

1916-20  . 

106 

5 

111 

12 

12 

442  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


Graph  28  (from  tables  102  and  110).  Crude  mortality  rates  from  tumors 
(cancer  and  other  tumors),  cardio-vascular-renal  diseases,  and  senility  and 
causes  unknown  in  adults,  averaged  by  five-year  periods,  from  1812  to  1920, 
inclusive. 

Table  103. — Number  of  deaths  and  the  rate  of  death,  per  100,000  living  inhabitants,  from 
cancer,  according  to  color  and  sex,  from  1900  to  1920,  inclusive. 


D  =  death.  R  =  rate. 


Year. 

Total. 

White. 

Colored. 

Total* 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R  i 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1900  . 

318 

63 

275 

64 

95 

46 

180 

81 

43 

55 

8 

23 

35 

81 

1901  . 

358 

70 

319 

73 

118 

56 

201 

90 

39 

49 

7 

20 

32 

73 

1902  . 

384 

74 

340 

77 

128 

60 

212 

93 

44 

55 

13 

36 

31 

70 

1903  . 

370 

70 

332 

74 

121 

56 

211 

92 

38 

47 

12 

33 

26 

58 

1904  . 

450 

84 

391 

87 

147 

67 

244 

105 

59 

71 

18 

49 

41 

90 

1905  . 

437 

81 

380 

83 

152 

68 

228 

97 

57 

68 

17 

45 

40 

87 

1906  . 

450 

82 

390 

84 

146 

65 

244 

103 

60 

71 

24 

63 

36 

77 

1907  . 

473 

85 

415 

89 

168 

74 

247 

103 

58 

67 

13 

33 

45 

95 

1908  . 

449 

80 

386 

82 

148 

64 

238 

99 

63 

72 

17 

43 

46 

96 

1909  . 

450 

79 

393 

82 

142 

61 

251 

103 

57 

64 

19 

47 

38 

78 

1910  . 

529 

92 

474 

98 

176 

74 

298 

121 

55 

61 

12 

30 

43 

88 

1911  . 

526 

91 

469 

96 

195 

82 

274 

110 

57 

63 

15 

36 

42 

85 

1912  . 

545 

93 

480 

98 

177 

73 

303 

121 

65 

71 

19 

45 

46 

92 

1913  . 

598 

101 

510 

103 

198 

81 

312 

124 

88 

94 

33 

78 

55 

108 

1914  . 

595 

100 

515 

'103 

205 

83 

310 

122 

80 

85 

20 

47 

60 

117 

1915  . 

627 

104 

564 

111 

235 

94 

329 

128 

63 

66 

28 

64 

35 

67 

1916  . 

636 

105 

550 

108 

261 

104 

290 

112 

85 

88 

25 

57 

60 

114 

1917  . 

640 

105 

568 

110 

255 

100 

313 

120 

72 

74 

23 

51 

49 

92 

1918  . 

637 

103 

564 

109 

234 

91 

330 

126 

73 

74 

29 

64 

44 

82 

1919  . 

749 

104 

660 

107 

286 

93 

374 

121 

89 

85 

27 

56 

62 

110 

1920  . 

827 

113 

724 

116 

332 

108 

392 

124 

103 

95 

37 

69 

66 

119 

VARIOUS  CHRONIC  ORGANIC  DISEASES 


443 


80  years  and  over  it  rose,  however,  to  985,  as  compared  with  1,252  for  white 
females.  For  1920,  the  rates  followed  somewhat  different  courses.  In  conse¬ 
quence  of  the  considerable  mortality  in  the  first  decade  and  the  absence  of 
mortality  in  the  second  decade  among  negroes,  the  rates  for  this  race  and  for 
the  total  population  were  higher  in  the  first  than  in  the  second  10  years  of 


Table  104. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from 
cancer,  according  to  age,  color,  and  sex,  for  1911  and  1920  * 


D  =  death.  R  =  rate. 


Age-period. 

Total. 

White. 

Colored- 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

I) 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1911 

Under  1  year. . . . 

1 

10 

1 

11 

•  •  • 

•  •  •  • 

1 

23 

Betw.  1  and  2  yrs. 

2  to  4  years. . . . 

1 

3 

1 

4 

1 

7 

5  to  9  years. . .  . 

0  to  9  years. . . . 

2 

2 

2 

2 

1 

2 

1 

o 

* 

10  to  19  years. . . . 

3 

3 

3 

3 

2 

5 

1 

2 

20  to  29  years. . . . 

14 

12 

11 

25 

5 

11 

6 

13 

3 

15 

1 

11 

2 

17 

30  to  39  years. . . . 

25 

28 

21 

29 

7 

20 

14 

37 

4 

25 

1 

13 

3 

37 

40  to  49  years. . . . 

78 

114 

61 

107 

20 

73 

41 

138 

17 

149 

4 

71 

13 

226 

50  to  59  years. . . . 

135 

299 

119 

305 

49 

259 

70 

347 

16 

264 

6 

203 

10 

322 

60  to  69  years. . . . 

115 

464 

104 

475 

40 

405 

64 

532 

11 

381 

2 

152 

9 

574 

70  to  79  years. . . . 

63 

603 

61 

645 

26 

660 

35 

634 

2 

201 

•  •  • 

•  •  • 

2 

337 

80  years  and  over 

30 

1123 

28 

1179 

9 

1049 

19 

1252 

2 

676 

•  •  • 

•  •  • 

2 

985 

Total  . 

465 

83 

410 

87 

159 

69 

251 

103 

55 

65 

14 

36 

41 

90 

mo 

Under  1  year.  — 

1 

7 

1 

8 

1 

15 

Betw.  1  and  2  yrs. 

1  3 

6 

2 

4 

1 

4 

1 

4 

1 

16 

1 

30 

2  to  4  years. . . . 

J 

5  to  9  years. . . . 

1 

2 

1 

2 

1 

4 

0  to  9  years. . .  . 

5 

8 

4 

3 

3 

5 

1 

2 

1 

6 

1 

12 

10  to  19  years. . . . 

5 

4 

5 

5 

•  •  • 

5 

9 

20  to  29  years. . . . 

18 

12 

14 

12 

8 

14 

6 

10 

4 

15 

2 

16 

2 

15 

30  to  39  years. . . . 

55 

45 

43 

43 

17 

34 

26 

52 

12 

55 

4 

36 

8 

74 

40  to  49  years. . . . 

151 

164 

120 

156 

48 

126 

72 

187 

31 

199 

8 

97 

23 

316 

50  to  59  years. . . . 

212 

339 

180 

329 

86 

322 

94 

335 

32 

407 

11 

259 

21 

581 

60  to  69  years. . . . 

214 

594 

198 

608 

101 

660 

97 

563 

16 

462 

8 

467 

8 

457 

70  to  79  years. . . . 

140 

971 

134 

1026 

63 

1126 

71 

952 

6 

442 

3 

496 

3 

399 

80  years  and  over 

27 

776 

26 

832 

6 

534 

20 

999 

1 

282 

1 

746 

•  •  • 

. . . 

Total  . 

827 

113 

724 

116 

332 

108 

392 

124 

103 

95 

37 

70 

66 

119 

*  The  rates  for  the  deaths  of  1911  are  calculated  on  the  1910  population  figures.  Data 
for  deaths  from  cancer,  according  to  distribution  for  age,  color,  and  sex,  are  lacking  for 
1910. 

life.  The  negro  rate  surpassed  the  white  rate  very  considerably  from  the 
thirtieth  to  the  sixtieth  year,  instead  of  but  slightly  from  the  fiftieth  to  the 
sixtieth  years,  as  in  1911.  In  1920,  the  rates  for  whites  continued  to  rise  until 
the  eightieth  year  and  then  declined,  while  the  negro  rates  ran  on  a  level 
between  the  sixtieth  and  the  eightieth  years  and  declined  through  the  re¬ 
mainder  of  life.  These  deviations  from  the  experience  of  1911  are  found  on 

29 


444  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

further  analysis  to  be  due  mainly  to  marked  increases  in  the  rates  for  negro 
females  before  the  sixtieth  year  and  declines  after  this  period,  and  to  a  con¬ 
siderable  augmentation  in  the  mortality  for  negro  males  throughout  life 
and  particularly  after  the  sixtieth  year. 

From  the  foregoing  account  of  the  relation  of  recorded  deaths  from  cancer 
and  tumor  to  the  Baltimore  population,  the  following  points  stand  out  with 
clear  cut  distinctness.  As  averaged  for  5-year  periods,  the  death-rates  of  these 
two  rubrics  taken  together  increased  from  4  for  period  1812-1815  to  111  for 
the  5  years  ending  in  1920,  an  increase  of  2,650  per  cent.  This  increase  was 
gradual  and  interrupted  until  1860,  and  abrupt  between  1860  and  1880.  But 
for  a  slight  recession  between  1881  and  1885  the  rates  rose  continuously  to 
the  end  of  the  period.  Of  the  great  increase  in  the  rates,  43  per  cent  occurred 
in  the  period  previous  to  1885.  Though  before  1910  under  the  rubric  tumor 
there  were  doubtless  included  a  not  inconsiderable  number  of  deaths  due  to 
malignant  or  cancerous  growths,  both  before  and  since  this  date,  in  compari¬ 
son  with  the  total  mortality,  its  rate  has  been  almost  negligible.  Therefore, 
in  analysis  of  various  factors  involved  in  explaining  the  marked  increase  in 
the  cancer  death-rate,  without  seriously  invalidating  results,  it  may  be  safely 
left  out  of  the  calculation.  Like  the  death-rates  for  cancer  and  tumor  com¬ 
bined,  those  for  cancer  have  shown  their  greatest  proportion  of  increase  since 
1885.  Since  1900,  at  least,  both  the  white  and  the  negro  race  and  both  sexes 
have  shared  in  this  increase  in  recorded  cancer  mortality.  In  this  period  the 
rates  for  cancer  have  been  higher  in  females  than  in  males,  higher  in  the 
aggregate  in  white  than  in  negro  females,  higher  in  white  than  in  negro  males. 
In  addition  to  confirming  these  results,  rates  specific  for  age,  calculated  for 
1911,  indicate  that  under  the  fortieth  and  over  the  fiftieth  years  of  age  cancer 
was  considerably  more  fatal  in  whites  than  in  negroes. 

If  these  observations  may  be  applied  to  the  whole  period  under  considera¬ 
tion,  it  is  obvious  that,  other  things  remaining  equal,  the  cancer  death-rate 
would  have  been  unfavorably  influenced  by  relative  increase  in  the  population 
of  whites,  especially  of  women,  of  females  of  both  races,  of  whites  40  years 
and  over,  and  of  negroes  between  the  fortieth  and  the  seventieth  years. 

As  it  has  been  found  that  of  the  deaths  ascribed  to  cancer  in  1911  and  1920 
only  a  small  proportion  occurred  in  individuals  below  the  fortieth  year,  and  an 
almost  negligible  proportion  in  those  under  the  thirtieth  year  of  age,  it  is  nec¬ 
essary,  in  reaching  an  approximately  correct  estimate  of  the  influence  of 
changes  in  the  age  distribution  of  the  population  upon  the  rate  of  cancer  mor¬ 
tality,  to  disregard  the  lower  age-groups  and  to  consider  only  those  portions 
of  the  population  above  these  two  ages.  Between  1830  and  1920  the  percentage 
of  the  population  40  years  of  age  and  over  increased  from  15.7  to  28.5  and 
that  30  years  and  over  from  29.2  to  54.8  of  the  whole,  or  by  75  and  55  per 
cent,  respectively.  But  this  notable  increase  in  the  proportion  of  the  popula¬ 
tion  in  the  age-period  most  susceptible  to  cancer  was,  however,  in  a  ratio  far 
below  the  recorded  increase  in  cancer  mortality.  Mortality-rates  for  cancer 
and  tumor  for  each  of  the  census  years  between  1830  and  1920,  calculated  on 
the  basis  of  the  population  at  all  ages  and  the  populations  over  the  twenty- 
ninth  and  thirty-ninth  years  of  life,  respectively,  are  given  in  table  105  and 
graph  29.  Whatever  their  specific  differences,  these  rates  follow  the  same  gen¬ 
eral  course  throughout.  Each  shows  an  ascent  more  or  less  gradual  until 


VARIOUS  CHRONIC  ORGANIC  DISEASES 


445 


Table  105. — Number  of  deaths  and  rate  of  death  per  100,000  living  inhabitants,  of  the  several 
age  groups,  population  at  all  ages,  30  years  and  over  and  40  years  and  over,  from  cancer 
and  tumor  and  from  senility  and  causes  unknown  in  adults,  for  the  census  years  1830-1920, 
inclusive. 


D  =  death.  R  =  rate. 


Census 

years. 

Population,  at  all  ages. 

Of  30  years 
and  over. 

Of  40  years  and  over. 

Cancer. 

Tumor. 

Cancer 

and 

tumor. 

Cancer. 

Tumor. 

. 

S-. 

<D  O 

v  S 

S5 

Cancer. 

Tumor. 

Cancer  k 

tumor. 

Senility. 

Causes 

unknown. 

D 

R 

D 

R 

D 

R 

R 

R 

R 

R 

R 

D 

I 

R 

D 

R 

1830  .... 

6 

7 

1 

1 

7 

9 

18 

3 

21 

26 

4 

31 

102 

450 

43 

190 

1840  .... 

9 

9 

3 

3 

12 

12 

29 

10 

39 

56 

19 

75 

104 

651 

32 

200 

1850  .... 

14 

8 

3 

2 

17 

10 

26 

6 

32 

48 

10 

59 

155 

535 

94 

325 

1860  .... 

30 

14 

4 

2 

34 

16 

42 

6 

47 

75 

10 

85 

197 

492 

144 

360 

1870  .... 

49 

18 

8 

3 

57 

21 

51 

8 

60 

87 

14 

101 

288 

513 

141 

251 

1880  .... 

174 

52 

34 

10 

208 

63 

139 

27 

167 

226 

44 

270 

252 

327 

14 

18 

1890  .... 

256 

59 

25 

6 

281 

65 

151 

15 

166 

247 

24 

271 

365 

352 

6 

6 

1900  .... 

338 

67 

35 

7 

373 

73 

164 

17 

181 

268 

28 

296 

357 

283 

•  •  • 

•  •  • 

1910  .... 

502 

90 

27 

5 

529 

95 

209 

11 

220 

331 

18 

349 

191 

126 

. . . 

•  •  • 

1920  .... 

789 

108 

27 

4 

816 

111 

238 

8 

246 

378 

13 

391 

60 

29 

. . . 

Senility 

and 

causes 

unknown. 


D 


R 


136 

249 

341 

429 

266 

371 

357 

191 

60 


145  640 


851 
860 

852 
764 
345 
358 
283 
126 

29 


*  In  each  instance  the  figures  for  the  number  of  deaths  represent  the  average  of  three  con¬ 
secutive  years,  namely,  the  census  year  and  the  year  immediately  preceding  and  succeeding. 


Graph  29  (from  tables  105,  110  and  116).  Mortality  rates  from  tumor 
(cancer  and  other  tumors),  cardio-vascular-renal  diseases,  and  senility  and 
causes  unknown  in  adults,  specific  for  age-group  40  years  of  age  and  over, 
for  the  census  years  1830  to  1920,  inclusive. 


446  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

1870  and  a  sharp  rise  to  a  much  higher  level  in  1880.  It  will  be  noted  that 
between  1880  and  1890  all  the  rates  were  stationary.  In  the  30  years  between 
1890  and  1920,  the  rates,  however  calculated,  exhibit  progressive  and  con¬ 
siderable  increases.  The  percentages  of  these  increases  in  different  portions  of 
the  period  are  shown  in  table  106. 

It  will  be  noted  that  the  greater  the  degree  of  correction  for  the  age-factor, 
the  smaller  the  percentage  of  increase  in  the  rates.  It  will  be  recognized  that 
this  method  fails  to  account  fully  for  the  effect  of  the  age-factor  upon  the  rates 
for  cancer  mortality,  for  here  it  has  been  assumed  that  all  increase  in  the 
proportional  increase  in  the  population  above  the  twenty-ninth  and  thirty- 
ninth  years  of  age  is  of  equal  consequence  in  this  respect.  However,  as  the 
risk  of  dying  of  cancer  increases  greatly  and  in  rising  ratios  from  decade  to 
decade  of  life  (table  104)  it  is  evident  that  increases  in  the  population  in  the 
higher  decades,  the  sixth,  seventh,  and  eighth,  for  instance,  must  exercise 
a  more  marked  influence  upon  the  cancer  risk  than  corresponding  increases 
in  the  fourth  and  fifth  decades.  As  a  matter  of  fact,  in  the  period  1890-1920 


Table  106. — Percentage  of  increase  from  one  period  to 
another  of  rates  shown  in  Table  105. 


Periods- 

Population 

of 

all  ages. 

Population 
30  years 
and  over. 

Population 
40  years 
and  over. 

1890  to  1920 . 

71 

49 

44 

1890  to  1900 . 

12 

9 

9 

1900  to  1910 . 

31 

22 

15 

1910  to  1920 . 

17 

12 

12 

1880  to  1890 . 

3 

•  • 

the  proportions  of  the  population  in  the  sixth,  seventh,  and  eighth  decades  of 
life  increased  by  21,  26,  and  19  per  cent,  respectively,  while  the  proportional 
increases  in  th,e  fourth  and  fifth  decades  were  only  4  and  16  per  cent.  So,  if 
it  were  possible  to  calculate  for  each  census  year  rates  specific  for  each  of  these 
decades  of  life,  correction  for  the  age-factor  would  become  more  striking. 
When  rates  for  cancer  alone  specific  for  age  for  the  census  years  1900,  1910, 
and  1920  are  applied  to  the  respective  age  distribution  of  a  standard  popula¬ 
tion  ( Glovers  Life  Table  for  the  United  States),  a  rise  in  the  rate  from  105 
in  1900  to  173  in  1920,  or  an  increase  of  65  per  cent,  becomes  apparent  in  this 
21-year  period  as  due  to  causes  other  than  age  influence. 

Among  the  possible  causes  other  than  actual  increase  in  incidence  and 
fatality  of  cancer,  perhaps  the  most  important  that  may  be  inquired  into  are 
improvement  in  medical  diagnosis  and  in  statistical  classification  of  deaths 
in  the  health  department.  The  influence  of  improvement  in  diagnosis  may  be 
tested  somewhat  roughly  in  the  following  fashion :  Deaths  recorded  as  due  to 
cancer  since  1875  can  be  separated  with  five  fairly  well-defined  groups: 
(1)  breast,  (2)  female  genitals  (uterus,  ovary,  vagina,  and  pelvis),  (3) 
oesophagus,  stomach,  and  liver,  (4)  intestines  and  peritoneum,  and  (5)  all 
other  organs.  The  first  four  groups  represent  respectively  rubrics  numbers 


VARIOUS  CHRONIC  ORGANIC  DISEASES 


447 


43,  42,  40,  and  41  of  the  International  Classification  of  Causes  of  Death, 
revision  of  1909. 

Cancer  of  the  breast,  equivalent  for  practical  purposes  to  cancer  of  the 
female  breast,  is  not  only  common  enough,  but  in  its  fatal  stage  is  easily 
recognizable.  It  is  the  best  example  of  accessible  or  open  cancer  of  frequent 
occurrence.  It  has  presented,  therefore,  little  opportunity  for  errors  in  diag¬ 
nosis  (in  fatal  stage)  and  of  classification.  Among  the  important  organs  not 
directly  on  the  surface  and  frequently  the  seat  of  fatal  cancer,  the  uterus  is 
the  most  readily  accessible  to  physical  examination.  Cancer  of  this  organ  can 
rarely  proceed  to  a  fatal  termination  without  giving  rise  to  clinical  symptoms 
and  physical  signs  which  would  not  baffle  the  diagnostic  powers  of  even  a  tyro 
in  medicine.  Cancer  of  the  ovary  and  “  of  the  pelvis,”  the  latter  appearing 
only  occasionally  in  the  records,  is  comparatively  rare,  and  is  easily  recog¬ 
nized  at  operation.  Since  1876,  however,  but  few  women  in  Baltimore  with 
ovarian  tumors  can  have  escaped  operation.  Nor  in  this  period  has  the  diag¬ 
nosis  of  the  relatively  rare  primary  cancer  of  the  vagina  and  the  external 
genitals  of  the  female  in  fatal  stages  presented  any  serious  difficulty.  In  cancer 
of  all  these  organs  the  important  problems  have  not  been  concerned  with  ulti¬ 
mate  but  rather  with  early  recognition,  and  with  operative  technique.  Malig¬ 
nant  growths  of  the  oesophagus,  though  not  exposed  to  direct  view  and  rela¬ 
tively  uncommon,  before  the  fatal  issue  give  rise  to  unmistakably  characteristic 
symptoms.  While  they  may  be  confused  with  cancer  of  the  cardiac  end  of  the 
stomach,  since  both  belong  to  the  same  rubric,  errors  of  differential  diagnosis 
as  between  cancer  of  these  two  organs  are  of  no  present  consequence.  The 
diagnosis  of  cancer  of  the  stomach,  even  yet  often  mistaken  in  fatal  cases,  has 
certainly  increased  very  greatly  in  accuracy  since  1875.  It  was  not  until  well 
after  this  date  that  Dr.  Saltzer  specialized  in  diseases  of  the  stomach  and 
introduced  the  newer  methods  of  gastric  analysis,  and  it  was  some  years  before 
the  routine  use  of  chemical  and  microscopical  methods  in  the  diagnosis  of 
diseases  of  the  stomach  by  Osier  in  his  clinic,  opened  in  1889,  was  adopted  in 
other  hospitals,  and  that  private  clinical  laboratories  were  established.  Nor 
was  it  before  1900  that  through  the  work  of  gastro-enterologists,  consulting 
internists,  laboratory  specialists  (including  roentgenologists),  and  surgeons, 
that  the  present  era  of  intensive  study  of  diseases  of  the  stomach  may  be  said 
to  have  opened  in  Baltimore.  It  is  evident,  therefore,  that  since  1876  the 
recognition  of  gastric  cancer  in  its  last  as  well  as  in  its  earlier  stages  has 
increased  progressively  in  accuracy.  As  this  organ  is  one  of  the  most  common 
seats  of  primary  cancer  in  both  sexes,  increased  precision  of  diagnosis  must 
have  exercised  an  important  role  in  the  observed  rise  in  the  crude  rates 
for  cancer. 

While  primary  cancer  of  the  liver  is  comparatively  rare,  of  the  important 
viscera  this  organ  is  the  one  which  is  most  frequently  the  seat  of  diagnoseable 
malignant  growths  originating  in  other  parts  of  the  body.  So  propitious  are 
conditions  in  this  organ  for  the  deposit  and  growth  of  metastases  that,  from 
primary  cancers  in  themselves  relatively  obscure,  it  is  often  the  seat  of  sec¬ 
ondary  growths  so  prominent  on  account  of  their  number  and  size  as  to  fix 
attention.  While  a  large  proportion  of  cancers  of  other  organs  of  digestion, 
as  the  oesophagus,  stomach,  intestines,  and  pancreas  metastasize  in  the  liver, 
it  is  also  often  involved  secondarily  from  malignant  growths  not  only  of  other 


448  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

abdominal  organs,  notably  the  uterus,  but  of  such  distant  parts  as  the  extremi¬ 
ties,  the  central  nervous  system,  the  eye,  and  the  skin.  In  consequence,  though 
these  pecularities  of  the  liver  often  determine  the  recognition  of  cancer  that 
would  be  otherwise  overlooked,  likewise  they  are  responsible  not  unfrequently 
for  errors  in  statistical  classification.  With  the  increase  of  knowledge  of  the 
pathology  of  cancer  and  the  improvement  in  diagnosis,  doubtless  in  many 
instances  deaths,  which  in  earlier  years  would  have  been  credited  to  cancer 
of  the  liver,  have  in  more  recent  years  been  assigned  in  the  statistical  classifica¬ 
tion  to  the  proper  organs  of  origin.  On  the  whole,  however,  it  may  be  assumed 
that  during  the  last  45  years  the  diagnosis  of  malignant  growths  falling 
under  our  third  group  has  undergone  a  very  decided  improvement. 

The  diagnosis  of  the  relatively  rare  cancer  of  the  small  intestines  has  been 
until  recent  years  comparatively  obscure.  The  diagnosis  and  statistical  classi¬ 
fication  of  cancer  of  the  colon  have  without  doubt  increased  greatly  in  precision, 
but  it  is  probable  that  a  considerable  proportion  of  deaths  from  cancer  of  the 
small  and  large  intestines  (the  rectum  excepted)  are  still  classified  under  in¬ 
testinal  obstruction  and  other  rubrics.  Cancer  of  the  rectum  is  comparatively 
accessible,  and  it  is  doubtful  if  in  its  terminal  stage  any  marked  improvement 
in  its  diagnosis  has  occurred  in  the  period  under  consideration.  Primary 
cancer  of  the  peritoneum  is  so  infrequent  as  to  be  of  relatively  minor  im¬ 
portance. 

Cancer  of  “  all  other  organs  ”  embraces  several  distinct  groups  of  malig¬ 
nant  tumors  which  vary  widely  in  the  ease  with  which  they  may  be  recog¬ 
nized.  Cancer  of  the  skin  (including  the  external  genitals),  the  nasal  and 
buccal  cavities,  the  eye,  the  larynx,  the  thyroid,  the  testes,  the  superficial 
lymph-glands,  the  subcutaneous  connective  tissue,  the  skeletal  muscles,  and 
the  bones,  which,  taken  together,  represent  a  very  considerable  proportion  of 
all  malignant  growths,  have  presented,  in  their  fatal  stages  at  least,  no  great 
difficulties  in  diagnosis  that  have  been  dissipated  by  recent  advances  in  medi¬ 
cal  knowledge.  In  this  respect  they  are,  for  the  most  part,  directly  comparable 
with  cancer  of  the  breast  and  uterus.  On  the  other  hand,  cancer  of  the  lungs 
and  pleura,  of  the  deeper  lymphatic  system,  of  the  bladder,  prostate,  and  kid¬ 
neys,  of  certain  abdominal  organs,  as  the  pancreas,  the  kidneys,  and  the 
adrenals,  and  of  the  central  nervous  system  compose  a  group  numerically  less 
significant  than  the  above  and  in  which  diagnosis  has  in  late  years  achieved 
very  considerable  progress.  Out  of  this  group,  during  the  last  10  years,  fell 
growths  of  the  brain,  many  of  which  are  malignant.  This  error  imposed  by 
official  rules  of  statistical  classification  has  been  more  than  counterbalanced, 
perhaps,  by  the  dispersion  to  the  proper  organs  of  origin  the  members  of  the 
old  statistical  group  “  cancer  diffused.”  It  seems  likely,  then,  that  in  a  sub¬ 
stantial  majority  of  instances  the  members  of  the  category  of  “  cancer  of  all 
other  organs  ”  were  as  readily  recognizable  in  1876  as  in  1920.  There  can  be 
no  doubt  that  the  increased  frequency  with  which  autopsies  have  been  con¬ 
ducted  by  trained  pathological  anatomists  in  both  homes  and  hospitals  since 
the  opening  of  the  Johns  Hopkins  Hospital  in  1889  has  contributed  very 
materially  to  correctness  of  diagnosis  and  in  consequence  of  statistical  classifi¬ 
cation  of  deaths  due  to  tumors. 

All  things  considered,  on  the  basis  of  increase  in  precision  of  diagnosis 
alone,  there  should  be  no  rise  in  the  mortality  from  cancer  of  the  breast  and 


VARIOUS  CHRONIC  ORGANIC  DISEASES 


449 


uterus,  but  the  advance  in  the  rates  for  cancer  of  the  oesophagus,  stomach,  and 
liver  should  be  considerable;  in  those  for  cancer  of  the  intestines  and  peri¬ 
toneum  very  marked;  and,  finally,  the  increase  in  the  rates  for  cancer  “  of  all 
other  organs  ”  should  be  somewhat  less  than  for  cancer  of  the  oesophagus, 
stomach,  and  liver.  The  crude  mortality  rates  for  these  various  categories  as 
averaged  for  5-year  periods  from  1876  to  1920,  inclusive,  are  compared  in 
table  107.  It  will  be  observed  that  though  the  rate  for  each  has  risen,  the 
increases  are  by  no  means  equal.  While  the  total  rate  for  cancer  increased  by 
125  per  cent  and  the  rates  for  cancer  of  the  breast  and  of  the  uterus  (and 
other  female  organs  of  generation)  rose  but  by  67  and  42  per  cent,  respectively, 
the  rate  for  cancer  of  the  oesophagus,  stomach,  and  liver  rose  by  160  per  cent, 
and  that  for  the  intestines  and  peritoneum  by  550  per  cent.  On  the  other 
hand,  the  rate  for  cancer  of  “  all  other  organs  ”  rose  by  only  125  per  cent,  or 
in  the  same  proportion  as  the  total  cancer  rate.  The  increase  in  the  rates  for 


Table  107. — Rate  of  death,  per  100,000  living  inhabitants,  by  5-year  periods,  from 

cancer,  from  1876  to  1920,  inclusive. 


Period- 

Grand 

total. 

Total 
rubrics  40 
and  41. 

Rubric  40. 

Rubric41. 

Total 
rubrics  42 
and  43. 

Rubric  42. 

Rubric43. 

All  other 
organs. 

Stomach, 
oesopha¬ 
gus  and 
liver. 

In¬ 

testines, 

rectum 

and 

perito¬ 

neum. 

Breast. 

Uterus 

ovaries 

and 

pelvis. 

1876-80  . 

47 

17 

15 

2 

18 

6 

12 

12 

1881-85  . 

50 

20 

16 

4 

19 

7 

11 

11 

1886-90  . 

57 

25 

20 

5 

22 

8 

14 

10 

1891-95  . 

59 

25 

21 

4 

22 

8 

15 

11 

1896-1900  . 

66 

29 

26 

4 

23 

8 

16 

14 

1901-05  . 

76 

38 

31 

8 

21 

8 

13 

16 

1906-10  . 

84 

42 

34 

8 

23 

8 

15 

19 

1910-15  . 

98 

48 

37 

11 

25 

9 

15 

26 

1916-20  . 

106 

52 

39 

13 

27 

10 

17 

27 

cancer  of  the  breast  and  of  the  female  generative  organs  was  notably  less  than 
it  was  in  those  for  the  other  three  categories,  and  the  advance  in  the  rates  for 
these  latter  categories  varied  roughly  with  the  scope  that  was  assumed  to  be 
available  for  the  effect  of  improvement  in  diagnosis.  But  it  was  assumed  that 
on  the  basis  of  improvement  in  diagnosis  the  rates  for  cancer  of  the  breast 
and  of  the  female  generative  organs  there  should  be  no  gain  at  all.  In  regard 
to  this  point,  it  is  significant  that  during  most  of  the  period,  i.  e.,  from  1886 
to  1910,  these  rates  were  practically  stationary.  The  slight  ascents  in  these 
rates  in  the  periods  before  and  after  these  dates  may  well  be  explained  by 
variables  yet  to  be  considered. 

If  the  mortality  for  tumors  as  a  whole  and  for  cancer  in  particular  has  not 
actually  but  only  apparently  risen  in  the  striking  ratio  the  official  figures 
would  seem  to  indicate,  under  what  statistical  rubrics  were  the  unaccounted- 
for  tumor  deaths  classified?  ’While  they  may  have  been  dispersed  perhaps 
under  many  rubrics  through  which  it  is  now  impossible  to  trace  them,  two 
rubrics,  causes  unknown  in  adults  and  senility,  probably  received  the  majority. 


450  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

The  rates  for  these  averaged  for  5-year  periods  are  compared  with  those  for 
tumors  in  table  102.  Similar  comparisons  are  made  for  the  census  years  1830 
to  1920,  inclusive,  in  table  105.  The  decline  in  the  rates  for  these  indefinite 
causes  much  more  than  counterbalances  the  ascent  in  the  rates  for  tumors. 
Though  there  is  ample  room  in  these  rubrics  for  hidden  cancer  (as  well  as 
for  other  causes  of  death  improperly  assigned),  even  if  the  higher  rates  of 
later  years  represented  no  actual  increase  in  cancer,  this  evidence  is  only  sug¬ 
gestive.  Another  heading  under  wdiich  some  cancer  deaths  may  well  be  con¬ 
cealed  is  intestinal  obstruction,  but  as  this  is  combined  in  the  same  rubric 
with  hernia,  comparison  is  not  here  attempted.  Since  1900,  and  particularly 
since  1910,  special  care  has  been  taken  in  the  division  of  statistics  of  the 
health  department  to  secure  full  and  accurate  classification  of  deaths  from 
tumors. 

In  addition  to  the  direct  influence  upon  cancer  mortality-rates,  which  it  has 
already  been  pointed  out  must  be  attributed  to  the  perfection  in  the  methods 
of  diagnosis  and  treatment  during  the  last  30  or  40  years,  there  must  be  taken 
into  consideration  the  possibility  of  an  indirect  effect.  It  is  a  well-established 
fact  that  since  1890  an  ever-increasing  number  of  individuals  with  cancer 
have  come  to  Baltimore  from  other  places  for  advice  and  treatment.  Some 
proportion  of  these  must  inevitably  die  here.  It  is  reasonable  to  suppose,  then, 
that  the  proportion  of  cancer  deaths  in  non-residents  was  low  in  the  early 
period  and  high  in  recent  years.  Unfortunately,  no  data  on  this  point  are 
recorded  before  1917.  However,  in  the  4  years  1917-1920,  inclusive,  on  an 
average,  17  per  cent  of  all  recorded  deaths  from  malignant  tumors  were  in 
non-residents — almost  all  of  whom,  it  is  certain,  were  attracted  to  the  city  by 
the  reputation  of  its  physicians  and  surgeons  in  diagnosis  in  general  and  in 
the  diagnosis  and  treatment  of  cancer  in  particular.  It  is  inconceivable  that 
in  early  years  non-residents  could  have  accounted  for  anything  approaching 
such  a  high  proportion  of  the  total  deaths  from  cancer.  Unhappily,  data  in 
regard  to  deaths  of  non-residents  from  benign  tumors  have  not  been  tabulated, 
but  it  is  well  known  that  each  year  an  appreciable  number  of  individuals  from 
out  of  town  with  growths  of  this  type  are  operated  on  by  local  surgeons  and 
that  some  fail  to  survive  the  experiment.  On  the  other  hand,  there  is  no  evi¬ 
dence  that  any  significant  proportion  of  residents  with  either  cancer  or  benign 
tumor  died  without  the  city.  Therefore  the  conclusion  is  forced  that  a  con¬ 
siderable  proportion  of  the  increase  in  cancer  mortality  in  later  years  is  to  be 
attributed  to  this  factor. 

In  respect  of  race,  there  has  been  a  steady  and  decided  decrease  in  the  per¬ 
centage  of  negroes  since  1880.  The  increase  of  females  over  males  in  the  gen¬ 
eral  population  has  hardly  been  great  enough  to  influence  the  tumor-rate 
significantly. 

Though  some  of  the  increase  in  the  recorded  mortality  previous  to  1870 
may  well  have  been  due  to  actual  augmentation  in  the  lethal  force  of  tumor, 
it  is  unreasonable  to  suppose  that  the  enormous  advance  in  the  rates  between 
1870  and  1880  can  be  thus  explained.  The  rates  recorded  for  1870  would 
hardly  have  covered  the  expected  mortality  from  all  tumors  readily  diag- 
noseable  at  that  time.  Evidently  diagnosis  and  statistical  classification  of 
tumors  up  to  this  time  must  have  been  poor.  It  is  likely,  then,  that  the  enor¬ 
mous  increase  in  the  tumor-rate  for  1880  as  compared  with  1870  was  due 


VARIOUS  CHRONIC  ORGANIC  DISEASES 


451 


largely,  if  not  entirely,  to  improvement  in  statistical  classification  of  deaths 
inaugurated  in  1875  by  Commissioner  James  A.  Steuart,  who  was  especially 
interested  in  statistics.  This  view  is  supported  by  the  facts  that  there  was  no 
increase  in  the  rates  for  cancer  and  tumor  between  1880  and  1890,  and  in 
these  10  years  but  little  progTess  was  made  in  the  precision  of  diagnosis  of 
cancer  of  internal  organs. 

If  the  foregoing  observations  and  assumptions  concerning  the  influence 
of  age,  sex,  race,  improvements  in  diagnosis  and  statistical  classification,  and 
the  increase  in  the  proportion  of  non-residents  dying  of  cancer  be  correct,  the 
course  of  the  rates  for  tumor  (including  cancer)  can  not  be  considered  to 
signify  an  actual  increase  in  lethal  force  in  the  period  up  to  1890.  If  this  be 
true,  the  bulk  of  the  hidden  tumor  deaths  must  have  been  classified  under 
some  other  rubric  or  rubrics  for  deaths  among  individuals  40  years  of  age  and 
over.  It  has  been  pointed  out  already  that  of  these,  senility  and  causes  unknown 
in  adults  are  the  most  likely  rubrics  to  contain  them. 

Since  between  1880  and  1890  there  was  practically  no  increase  in  the  rates 
for  tumors,  however  calculated,  the  further  course  of  these  affections  covers 
the  30  years  since  1890.  It  has  been  shown  that,  since  1900,  35  per  cent  in 
the  increase  in  the  mortality-rate  is  explained  by  changes  in  the  age  distribu¬ 
tion  of  the  population.  Of  the  remainder,  a  large  part  must  have  been  due  to 
advance  in  precision  in  medical  diagnosis,  continued  improvement  in  statisti¬ 
cal  classification,  and  the  probable  augmentation  of  deaths  of  non-residents. 
While  they  cast  considerable  doubt  upon  the  question,  these  considerations 
do  not  prove  that  there  has  been  no  real  increase  in  the  mortality  from  tumors 
(including  cancer)  in  Baltimore.  Nor  in  this  discussion  has  any  offset  been 
allowed  for  any  reduction  in  mortality  that  should  have  occurred,  if  surgeons 
are  correct  in  their  claims  of  definite  cures  of  cancer  of  certain  organs  and  of 
the  successful  removal  of  benign  tumors  of  various  organs,  such  as  the  uterus 
and  ovary,  that  if  left  alone  must  have  caused  deaths. 

There  remains  yet  another  test  that  may  be  applied  to  this  material,  with 
some  hope  of  getting  a  clear-cut  answer  that  will  cover  these  objections  so  far 
as  cancer  is  concerned.  The  diagnosis  of  cancer  of  the  breast  and  uterus  in 
lethal  stages  can  not  be  justly  held  to  have  improved  significantly  since  1880. 
However,  since  1890,  and  particularly  since  1900,  operative  technique  for 
their  cure  has  certainly,  as  the  result  primarily  of  the  work  of  Halsted  and 
Kelly  and  their  associates,  been  greatly  perfected,  and  of  late  years  many  other 
capable  surgeons  have  adopted  like  methods.  If  there  has  been  no  actual 
increase  in  the  mortality  from  cancer  of  these  two  organs,  then  rates  specific 
for  sex  and  age  should  show  no  significant  increase  between  1880  and  1890, 
and  an  actual  and  not  insignificant  decrease  since  the  latter  date.  Rates 
averaged  for  5-year  periods  from  1876  to  1920,  inclusive,  for  these  two  cate¬ 
gories,  in  respect  of  the  total  female  population,  that  is,  rates  specific  for  sex 
alone,  are  given  in  table  108.  Since  1880,  the  percentages  of  increase  in  mor¬ 
tality  were,  for  the  breast  43,  for  the  uterus  50,  and  for  the  two  together  47. 
It  is  noteworthy  that  for  cancer  of  the  uterus  these  rates  showed  a  little  change 
between  1895  and  1915;  and  that  those  for  cancer  of  the  breast  were  prac¬ 
tically  stationary  from  1880  to  1910.  For  cancer  of  the  breast  since  1910 
and  for  cancer  of  the  uterus  since  1915  these  rates  advanced  considerably.  As 
for  practical  purposes  deaths  from  cancer  of  the  breast  and  uterus  may  be 


452  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


taken  as  confined  to  the  age-period  40  years  and  over,  and,  since  1880,  the 
population  figures  of  this  age-gronp  for  females  is  available,  it  is  possible  to 
calculate  rates  reasonably  specific  for  the  actual  population  exposed  to  the 
risk  of  death  from  cancer  of  these  organs  for  the  census  years  1880  to  1920, 
inclusive.  From  these  data,  presented  in  table  109,  it  appears  that  after  1880 
there  was  no  increase  in  mortality  from  cancer  of  the  breast,  and  since  1890 


Table  108. — Rate  of  death,  'per  100,000  living  female  inhabitants,  by  averaged  5-year 
periods,  from  cancer  of  the  breast,  uterus,  ovaries,  and  pelvis,  from  1876  to  1920, 
inclusive. 


Period. 

Total. 

Breast. 

Uterus, 

ovaries 

and 

pelvis. 

Period. 

Total. 

Breast. 

Uterus, 

ovaries 

and 

pelvis. 

1876-80  . 

34 

12 

22 

1901-05  . 

40 

15 

25 

1881-85  . 

36 

14 

22 

1906-10  . 

45 

16 

30 

1886-90  . 

42 

16 

26 

1911-15  . 

48 

18 

30 

1891-95  . 

43 

15 

28 

1916-20  . 

53 

20 

33 

1896-1900  _ 

44. 

14 

30 

none  from  cancer  of  the  uterus.  On  the  contrary,  since  1910,  there  has  been 
a  notable  decrease  in  mortality  from  cancer  of  the  breast,  and  since  1890  from 
cancer  of  the  uterus  and  from  cancer  of  these  two  organs  taken  together.  Thus, 
when  rates  that  approach  specificity  are  obtained,  in  respect  to  cancer  of  these 
two  organs,  in  which  the  disease  in  fatal  stages  is  readily  diagnoseahle,  an 
apparent  increase  in  mortality  is  converted  into  an  actual  decrease.  Therefore 


Table  109. — Number  of  deaths  and  the  rate  of  death,  per 
100,000  living  female  inhabitants,  JfO  years  of  age 
and  over,  from  cancer  of  the  breast  and  uterus,  for 
the  census  years  1880  to  1920,  inclusive. 


D  =  death.  R  =  rate. 


Year. 

Popula¬ 

tion. 

Total. 

Breast. 

Uterus. 

D 

R 

D 

R 

D 

R 

1880  . 

40936 

94 

230 

37 

90 

57 

139 

1890  . 

59278 

158 

286 

50 

90 

108 

195 

1900  . 

66811 

161 

241 

52 

78 

109 

162 

1910  . 

80079 

199 

249 

74 

93 

125 

156 

1920  . 

106902 

205 

192 

80 

75 

125 

117 

it  seems  to  be  established  that,  during  the  last  40  years,  cancer  of  the  breast 
and  uterus  (including  the  other  female  organs  of  generation)  has  shown  no 
real  advance  in  mortality,  and  that  there  is  a  considerable  margin  of  reduc¬ 
tion,  especially  in  respect  of  the  latter  category,  to  be  placed  probably  to  the 
credit  of  surgical  interference. 

As  the  operative  mortality  for  cancer  of  these  two  seats  is  comparatively 
slight,  the  question  of  deaths  among  non-residents  is  here  relatively  of  neg¬ 
ligible  importance. 


VARIOUS  CHRONIC  ORGANIC  DISEASES 


453 


Since  1890  these  speciiic  rates  for  cancer  of  the  breast  and  uterus  have  fallen 
by  25  and  42  per  cent,  respectively.  As  spontaneous  recovery  from  cancer  of 
these  organs  is  unknown,  unless  the  disease  has  decreased  correspondingly  in 
incidence — and  for  this  there  is  no  evidence — these  figures  may  be  taken  as 
measuring  in  a  general  way  the  effect  upon  mortality  of  earlier  diagnosis  and 
improved  measures  of  mechanical  treatment.  It  is  not  unreasonable  to  sup¬ 
pose  that  in  the  last  20  years  at  least  comparable  results  have  been  obtained 
in  cancer  of  some  certain  other  organs,  such  as  the  skin,  lip,  tongue,  bones, 
and  rectum,  and  that  cures  have  been  made  at  least  occasionally  of  cancers 
of  other  organs. 

These  disclosures  in  regard  to  cancer  of  these  two  accessible  organs  indicate 
very  definitely  that  such  proportions  of  the  advances  in  the  crude  rates  for 
cancer  of  all  other  organs  as  are  not  dependent  upon  changes  in  the  age,  sex, 
and  race  distribution  of  the  population  should  be  attributed  to  improvements 
in  diagnosis  and  statistical  classification  and  to  relative  increases  in  the  num¬ 
ber  of  deaths  of  non-residents  with  cancer  coming  to  the  city  for  diagnosis 
and  treatment  and  not  to  an  actual  increase  in  mortality.  In  regard  to  benign 
tumors,  it  will  be  noted  from  table  102  that  there  was  but  little  increase  in  the 
crude  rates  for  tumors  between  1890  and  1905  and  an  actual  decrease  since 
the  latter  date.  Tins  means  that,  when  corrected  for  age,  the  rate  for  tumor 
unqualified  has  declined  in  the  last  30  years  and  that  most  of  this  decline  has 
occurred  since  1905.  After  1890,  at  least,  most  of  the  deaths  ascribed  to  tumor 
were  associated  with  benign  tumors  of  the  uterus  and  ovary.  It  is  evident, 
then,  that  in  this  period  there  has  been  a  fall  in  the  death-rate  from  tumors  of 
this  class.  In  Baltimore  gynaecologists  and  general  surgeons  have  been  operat¬ 
ing  with  success  upon  such  tumors  of  the  ovary  since  1870  and  of  the  uterus 
since  1890.  The  situation  is  complicated,  however,  by  the  fact  that  a  large 
proportion  of  the  operations  and  a  considerable  proportion  of  the  deaths  were 
in  non-residents.  On  the  whole,  the  decline  in  the  rates  for  benign  tumors 
may  be  taken  probably  as  indicative  of  improved  surgical  technique.  No 
administrative  measures  designed  to  influence  the  incidence  and  mortality  of 
cancer  have  been  undertaken. 


Chapter  XIV. — Diseases  of  the  Cardio-vascular- 

renal  System. 

(Tables  101,  110  to  116,  graphs  27  to  29.) 

Under  this  general  heading  will  be  discussed  the  course  of  recorded  mor¬ 
tality  from  certain  affections  of  the  heart,  blood-vessels,  and  kidneys.  Some 
of  these  affections  are  almost  hopelessly  mixed,  and  in  many  instances  it  is 
impossible  to  decide  definitely,  even  at  autopsy,  to  which  one  of  several  cate¬ 
gories  a  particular  death  should  be  classified.  But  slight  experience  in  this 
field  reveals  convincing  evidence  that  in  many  instances  the  classification  of 
a  given  death  to  one  rubric  instead  of  to  another  is  determined  by  the  chance 
that  a  physician  used  one  term  instead  of  another  equally  appropriate  to  define 
either  the  primary  or  the  secondary  cause  of  death.  This  complication  has 
been  accentuated  in  some  respects  by  the  classification  rules  of  the  Bureau  of 
the  Census.  It  will  soon  appear  that  it  has  not  been  possible  to  follow  and  to 
include  all  of  the  rubrics  under  diseases  of  the  circulation  and  of  the  kidneys. 
Because  diseases  of  the  venous  system,  thrombosis,  and  calculi  and  suppurative 
affections  of  the  kidneys  could  not  be  traced  and  accounted  for  in  the  earlier 
years,  they  have  been  omitted  from  consideration  in  later  years.  Nor  is  it 
possible  in  the  available  data  to  study  acute  and  chronic  affections  separately. 

The  diseases  of  the  organs  under  immediate  consideration  occur  in  the 
statistical  nosology  under  a  variety  of  headings,  which  for  convenience  are  here 
assembled  under  the  following  rubrics :  Organic  diseases  of  the  heart,  apoplexy 
and  softening  of  the  brain,  arterio-sclerosis,  Bright’s  disease  of  the  kidneys, 
and  general  dropsy.  After  a  brief  account  of  the  evolution  of  these  rubrics, 
the  course  of  the  recorded  mortality  for  each  will  be  traced,  and  then  the  group 
as  a  whole  will  be  considered. 

Deaths  from  affections  of  the  heart  appeared  in  the  mortality  tables  for  the 
first  time  in  1824  under  the  heading  organic  disease  of  the  heart,  a  statistical 
rubric  which  has  persisted  ever  since.  With  the  considerable  expansion  of  the 
lists  of  the  causes  of  death  after  1875,  as  refinements  of  classification  there 
were  added  numerous  other  rubrics,  such  as  pericarditis,  endocarditis,  acute 
and  chronic,  mitral  and  aortic  regurgitation,  cardiac  dropsy,  and  the  like. 
Angina  pectoris,  after  appearing  in  1827,  disappeared  completely  until  1875, 
and  during  those  40-odd  years  deaths  from  this  cause  were  classified  under 
organic  diseases  of  the  heart.  Since  1875  deaths  have  been  attributed  to 
angina  pectoris  in  each  year.  After  the  adoption  of  the  international  list  of 
the  causes  of  death  in  1899,  deaths  attributed  to  affections  of  the  heart  have 
been  distributed  among  four  rubrics — pericarditis,  endocarditis,  organic  dis¬ 
ease  of  the  heart,  and  angina  pectoris.  It  is  evident  from  the  foregoing  that 
these  rubrics  can  not  be  traced  consistently  before  the  latter  date,  and  that 
the  old  statistical  rubric,  organic  disease  of  the  heart,  as  used  before  1875, 
embraced  all  deaths  certified  as  due  to  disease  of  any  of  the  various  structural 
454 


VARIOUS  CHRONIC  ORGANIC  DISEASES 


455 


portions  of  this  organ  and  therefore  deaths  classifiable  under  these  four  mod¬ 
ern  rubrics.  On  this  account,  in  any  attempt  to  trace  correctly  the  course  of 
the  force  of  mortality  of  cardiac  affections  associated  with  structural  changes, 
it  is  necessary  to  treat  these  under  one  generic  heading,  organic  diseases  of 
the  heart. 

In  this  connection,  for  the  sake  of  clearness,  it  may  be  pointed  out  that, 
as  used  in  contrast  to  pericarditis,  acute  endocarditis,  and  angina  pectoris, 
the  rubric  organic  disease  of  the  heart  in  the  international  system  of  classifica¬ 
tion  of  causes  of  death  from  1900  to  1920  is  absolutely  illogical  and  may  lead 
the  unwary  into  serious  error.  The  adjective  organic  is  here  used  to  indicate 
disease  of  structure  as  opposed  to  aberrations  of  function  alone.  Pericarditis 
and  acute  endocarditis,  however,  convey  the  concept,  disease  of  organic  struc¬ 
ture,  just  as  positively  and  as  clearly  as  do  myocarditis  and  chronic  endocarditis, 
which  as  certified  causes  of  death  are  classed  with  some  others  under  organic 
diseases  of  the  heart.  The  rubric  under  criticism  is  designed  to  include  deaths 
from  other  organic  diseases  of  the  heart  than  those  which  by  definition  are 
embraced  under  the  three  remaining  rubrics.  While  angina  pectoris  without 
structural  changes  demonstrable  by  ordinary  methods  may  in  exceptional  cases 
be  fatal,  in  the  great  bulk  of  cases  which  have  been  examined  at  autopsy  by 
competent  pathologists  very  definite  structural  changes  in  the  arteries,  muscles, 
or  valves  of  the  heart  have  been  demonstrated.  In  the  present  section  the  term 
organic  disease  of  the  heart  is  used  in  its  broad  and  proper  sense,  and  the 
figures  presented  for  each  year  represent  the  sum  of  the  deaths  recorded  under 
any  and  all  rubrics  implying  structural  changes  of  the  heart,  including  the 
pericardium.  Angina  pectoris  is  the  only  one  of  these  rubrics  that  can  be 
followed  separately  for  any  considerable  number  of  years. 

Previous  to  1899,  deaths  from  apoplexy  (including  cerebral  congestion  and 
hemorrhage)  and  softening  of  the  brain  were  recorded  in  each  year,  under 
apoplexy  from  1813,  congestion  of  the  brain  from  1841,  and  hemorrhage  of 
the  brain  from  1875.  During  the  years  in  which  these  three  rubrics  occurred 
together,  apoplexy  was  always  credited  with  the  largest  number  of  deaths,  and, 
on  the  whole,  next  in  importance  stood  congestion  of  the  brain.  In  1899  these 
three  categories  were  combined  in  the  single  rubric,  congestion  and  hemorrhage 
of  the  brain  and  apoplexy,  and  with  the  revision  of  the  international  classifica¬ 
tion  effective  in  1910  this  became  rubric  64.  However,  before  1875,  the  mor¬ 
tality  reports  carried  the  rubric  hemorrhage  without  specified  organ,  to  which 
doubtless  some  deaths  actually  due  to  cerebral  hemorrhage  were  assigned. 
To  the  rubric  softening  of  the  brain,  since  its  introduction  in  1868,  deaths 
have  been  credited  in  every  year  except  1898.  In  some  of  the  earlier  years 
after  its  introduction  the  number  of  deaths  assigned  to  this  rubric  amounted 
to  as  much  as  one-third  of  the  number  classified  under  apoplexy,  but  since  1890 
the  rubric  softening  of  the  brain  has  steadily  declined  in  relative  importance. 

In  this  section  the  deaths  classified  under  congestion  and  hemorrhage  of  the 
brain  and  apoplexy  have  been  placed  under  a  single  rubric  corresponding  to 
the  present  rubric  64  of  the  international  classification,  and  thus  for  conven¬ 
ience  will  be  called  apoplexy.  There  can  be  no  doubt  that  the  two  rubrics  of 
the  statistical  nosology,  apoplexy  and  softening  of  the  brain,  have  been  used 
throughout  the  whole  period  for  deaths  due  to  affections  falling  under  the  same 


456  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

clinical  and  anatomical  categories,  namely,  loss  of  consciousness  with  paraly¬ 
sis,  caused  in  the  vast  majority  of  instances  by  lesions  of  the  cerebral  blood¬ 
vessels.  For  present  purposes  it  is  unimportant,  whether  the  resulting  injury 
to  the  brain  be  brought  about  directly  by  anaemia  due  to  closure  of  blood¬ 
vessels  from  thrombosis,  embolism,  sclerosis,  or  by  spasmodic  contraction  of 
the  cerebral  vessels,  resulting  or  not  in  necrosis  (with  softening)  of  brain 
tissue,  or  by  pressure  (and  anaemia)  cause  by  oedema  or  by  actual  vascular 
rupture  with  hemorrhage.  As  a  matter  of  fact,  in  many  instances,  differential 
diagnosis  can  be  made  with  certainty  only  at  autopsy.  In  any  case,  the  injury 
to  the  brain  is  almost  always  secondary  to  lesions  primarily  vascular,  and  in 
the  great  majority  of  cases  associated  with  hemorrhage  into  the  brain-tissue. 
In  a  certain  proportion  of  instances  apoplexy  is  caused  by  the  plugging  of  one 
or  more  cerebral  vessels  by  emboli  from  the  heart,  usually  associated  with  acute 
endocarditis,  and  in  recent  times  a  large  moiety  of  deaths  so  caused  have  been 
assigned  under  the  rules  to  the  primary  cardiac  disease. 

No  direct  recognition  of  arterial  disease  appeared  in  the  mortality  tables 
until  1875,  when  7  deaths  were  classified  under  aneurism.  In  each  succeeding 
year  until  1899,  with  one  exception,  a  few  deaths  were  assigned  to  this  rubric. 
The  highest  number  in  any  one  year  was  20  in  1897.  In  1898,  to  the  new 
rubrics,  atheroma  and  arterial  sclerosis,  a  few  deaths  were  credited.  In  1899, 
these  three  rubrics  were  combined  in  the  single  rubric,  diseases  of  the  arteries, 
which  has  since  grown  steadily  in  importance. 

The  earliest  mention  of  renal  affections  in  the  mortality  records  was  in  1822, 
when  1  death  was  recorded  from  nephritis,  a  term  which  did  not  appear  again 
until  1847.  Inflammation  of  the  kidneys,  credited  with  1  death  in  1828,  and 
with  from  1  to  2  deaths  in  9  of  the  following  19  years,  appeared  in  the  statisti¬ 
cal  nosology  each  year  between  1854  and  1897.  For  most  of  this  period  this 
was  the  chief  rubric  under  which  deaths  from  renal  disease  were  recorded. 
To  albuminuria,  which  appeared  first  in  1875,  a  few  deaths  were  attributed 
nearly  every  subsequent  year  until  1899.  The  rubric  Bright’s  disease,  intro¬ 
duced  for  the  first  time  in  1872,  gradually  increased  relatively  in  importance 
and  after  1898  completely  superseded  the  other  rubrics  and  became  the  sole 
statistical  repository  for  deaths  from  non-suppurative  diseases  of  the  kidneys. 
In  a  few  years  before  1899,  1  or  2  deaths  were  attributed  to  renal  calculi  or 
to  renal  abcess.  Not  until  1899  was  a  clear-cut  attempt  made  to  distinguish 
between  deaths  due  to  Bright’s  disease  in  the  ordinary  medical  meaning  of 
the  term  and  those  due  to  affections  of  the  kidneys  associated  with  calculi 
and  with  primary  and  secondary  tuberculosis  and  suppuration  of  these  organs. 
However,  since  these  affections  are  relatively  rare  as  compared  with  Bright’s 
disease,  for  the  present  discussion  they  may  be  disregarded.  Since  1900  acute 
and  chronic  Bright’s  disease  have  been  classified  separately. 

The  rubric  dropsy  or  general  dropsy  appeared  continuously  in  the  mortality 
tables  from  1812  to  very  recent  years.  As  illustrative  of  its  importance  in  the 
statistical  nosology  in  earlier  times,  in  typical  years  the  number  of  deaths 
assigned  to  this  rubric  were  58  in  1827,  57  in  1840,  118  in  1850,  149  in  1860, 
195  in  1870.  In  some  years  these  figures  were  greatly  exceeded.  Between 
1875  and  1898  this  rubric  was  split  into  general,  cardiac,  renal,  and  ab¬ 
dominal  dropsy.  After  1875,  with  the  rapid  and  continuous  expansion  of 
rubrics  for  heart  disease,  general  dropsy  steadily  decreased  in  importance,  and 


VARIOUS  CHRONIC  ORGANIC  DISEASES 


457 


by  1910  had  become  insignificant.  In  the  compilation  of  the  tables  for  this 
section,  deaths  from  cardiac  and  renal  dropsy  have  been  assigned  to  heart  and 
renal  diseases,  respectively,  and  deaths  from  abdominal  dropsy  to  cirrhosis  of 
the  liver.  Under  dropsy  have  been  tabulated  only  deaths  classified  as  due  to 
dropsy  unqualified  and  to  general  dropsy. 

With  the  foregoing  explanation  of  the  sources  and  the  order  of  the  data  at 
hand,  consideration  of  the  course  of  mortality  under  the  several  rubrics  will 
be  undertaken.  The  number  of  officially  recorded  deaths  each  year  between 


Table  110. — Average  rate  of  death,  per  100,000  living  inhabitants,  by  5-year  periods, 
from  diseases  of  the  cardio-vascular-renal  system,  senility,  causes  unknown  (adult), 
and  tumors,  from  1812  to  1920,  inclusive. 


Periods. 

Cardio-vascular-renal  system. 

Senility  and 
causes  unknown. 

Grandtotal  cardio-vascular- 

renal  system,  senility 

and  causes  unknown- 

Total  tumors. 

Diseases  of  the 
heart. 

Dropsy. 

Aneurysm  and 
arterio-sclerosis- 

Nephritis. 

Total,  excluding 
apoplexy  and  soft¬ 
ening  of  the  brain. 

Apoplexy  and  soft¬ 
ening  of  the  brain. 

1 

Total. 

-4-> 

•H 

•  H 

3 

<u 

m 

Causes  unknown 

(adult). 

Total- 

1812-15  . 

82 

82 

10 

92 

145 

145 

237 

4 

1816-20  . 

71 

71 

38 

109 

123 

123 

232 

8 

1821-25  . 

3 

58 

61 

24 

85 

120 

39 

159 

244 

6 

1826-30  . 

3 

64 

•  •  •  • 

67 

17 

84 

119 

56 

175 

259 

9 

1831-35  . 

7 

33 

i 

41 

25 

66 

126 

30 

156 

222 

8 

1836-40  . 

7 

49 

i 

57 

21 

78 

95 

22 

117 

195 

11 

1841-45  . 

20 

36 

i 

57 

16 

73 

76 

40 

116 

189 

11 

1846-50  . 

27 

57 

2 

86 

18 

104 

96 

74 

170 

274 

13 

1851-55  . 

36 

75 

3 

114 

25 

139 

100 

56 

156 

295 

14 

1856-60  . 

45 

64 

5 

114 

24 

138 

94 

73 

167 

305 

13 

1861-65  . 

42 

70 

3 

115 

17 

132 

85 

63 

148 

280 

16 

1866-70  . 

50 

81 

6 

137 

21 

158 

89 

62 

151 

309 

23 

1871-75  . 

62 

68 

15 

145 

42 

187 

100 

36 

136 

323 

30 

1876-80  . 

84 

22 

1 

31 

138 

70 

208 

72 

4 

76 

284 

54 

1881-85  . 

107 

15 

2 

43 

167 

70 

237 

77 

3 

80 

317 

50 

1886-90  . 

109 

7 

3 

60 

179 

78 

257 

74 

1 

75 

332 

63 

1891-95  . 

119 

7 

3 

88 

217 

82 

299 

80 

80 

379 

64 

1896-1900  . 

122 

4 

9 

120 

255 

77 

332 

65 

65 

397 

73 

1901-05  . 

142 

2 

22 

143 

309 

74 

383 

54 

54 

437 

83 

1906-10  . 

163 

1 

24 

170 

358 

66 

424 

41 

41 

465 

89 

1911-15  . 

172 

•  •  •  • 

38 

171 

381 

86 

467 

28 

.... 

28 

495 

102 

1916-20  . 

194 

•  •  •  • 

25 

169 

388 

120 

508 

12 

12 

520 

110 

1824  and  1920  from  organic  disease  of  the  heart  as  above  defined  and  the 
mortality-rates  calculated  therefrom  are  given  in  table  101.  With  rather  wide 
fluctuations  from  year  to  }rear  the  mortality-rates  rose  from  3  in  1824  to  10  in 
1835,  17  in  1840,  32  in  1846,  49  in  1851,  and  63  in  1870.  With  considerable 
annual  variations,  the  rates  rose  gradually  during  the  next  three  decades  to 
126  in  1900.  From  this  date  there  was  an  almost  uninterrupted  ascent  in  the 
rates  to  248  in  1918,  with  an  abrupt  fall  to  167  in  1919,  succeeded  by  a  rise 
to  180  in  1920. 

The  annual  rates  averaged  for  quinquennial  periods  (table  110)  show  no 
significant  rise  between  1821  and  1840.  Except  for  a  slight  setback  for  the 


458  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

period  1861-1865,  there  was  a  steady  ascent  in  the  averaged  rates  from  20  for 
the  quinquennium  1841-1845,  to  62  for  that  ending  in  1875.  The  rate  of 
increase  was  considerably  accelerated  during  the  next  10  years,  but  there 
was  no  significant  advance  during  the  quinquennium  1886-1890.  From  109 
for  the  latter  period,  the  rates  advanced  to  119  for  1891-1895,  and  after  again 
remaining  almost  stationary  for  the  succeeding  5  years,  they  jumped  steadily 
upwards  after  1901,  and  for  the  period  ending  in  1920  stood  at  194. 

The  influence  of  age  upon  mortality  from  organic  diseases  of  the  heart  in 
1920  upon  the  whole  population  and  upon  whites  and  negroes  taken  sepa¬ 
rately  is  shown  in  table  111.  The  data  used  include  deaths  recorded  officially 
under  pericarditis,  endocarditis,  organic  disease  of  the  heart,  and  angina  pec¬ 
toris,  but  not  those  under  congenital  malformation.  For  the  whole  population 


Table  111. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from 
organic  diseases  of  the  heart,  according  to  age,  color,  and  sex,  for  1920. 


D  =  death.  R  =  rate. 


Age-period. 

Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

Under  1  year . 

.... 

1  to  4  years . 

3 

6 

1 

2 

.  .  . 

.... 

1 

4 

o 

31 

1 

32 

1 

30 

5  to  9  years . 

11 

17 

10 

18 

4 

14 

6 

22 

1 

12 

1 

26 

•  •  • 

•  •  •  • 

0  to  9  years . 

14 

10 

11 

9 

4 

7 

7 

12 

3 

18 

2 

25 

1 

12 

10  to  19  years . 

42 

34 

31 

29 

20 

38 

11 

20 

11 

69 

4 

57 

7 

79 

20  to  29  years . 

60 

41 

37 

31 

18 

31 

19 

32 

23 

89 

13 

107 

10 

73 

30  to  39  years . 

98 

80 

61 

61 

30 

59 

31 

62 

37 

170 

25 

226 

12 

111 

40  to  49  years . 

168 

182 

97 

126 

51 

134 

46 

119 

71 

456 

42 

507 

29 

398 

50  to  59  years . 

253 

404 

178 

325 

108 

405 

70 

250 

75 

954 

35 

825 

40 

1107 

60  to  69  years . 

276 

767 

224 

688 

113 

738 

111 

644 

52 

1501 

25 

1459 

27 

541 

70  to  79  years . 

292 

2026 

268 

2052 

117 

2090 

151 

2024 

24 

1770 

13 

2149 

11 

1465 

80  years  and  over. 

163 

4684 

154 

4926 

49 

4363 

105 

5242 

9 

2542 

2 

1493 

7 

3182 

Total  . 

1366 

186 

1061 

170 

510 

165 

551 

174 

305 

282 

161 

302 

144 

260 

by  decennial  periods  the  rates  were  10  for  the  first,  34  for  the  second,  41  for 
the  third,  80  for  the  fourth,  182  for  the  fifth,  404  for  the  sixth,  767  for  the 
seventh,  2,026  for  the  eighth,  and  4,684  for  the  eightieth  year  and  over.  The 
mortality,  but  slight  before  the  thirtieth  year,  increases  progressively  from 
this  period  into  old  age.  For  every  age-group  below  the  seventieth  year,  the 
force  of  mortality  is  higher  in  negroes  than  in  whites  and  for  every  decade  of 
life  from  the  first  to  the  seventh,  inclusive,  the  mortality-rate  for  the  former 
is  more  than  double  that  for  the  latter.  From  the  thirtieth  year  in  whites 
and  from  the  twentieth  in  negroes  the  rates  increase  sharply  and  progressively 
with  advancing  years.  In  the  white  race  the  mortality  in  females  is  consider¬ 
ably  higher  than  that  for  males  in  the  first  decade  of  life,  with  rates  of  12 
and  7,  respectively.  This  condition  is  reversed  in  the  second  decade,  but 
between  the  twentieth  and  thirty-ninth  years  the  rates  for  the  two  sexes 
are  almost  identical.  Beween  the  fortieth  and  the  seventy-ninth  years  the 
mortality-rates  are  decidedly  higher  in  males,  but  from  the  eightieth  year  the 


VARIOUS  CHRONIC  ORGANIC  DISEASES 


459 


advantage  is  with  the  latter.  Among  negroes,  below  the  tenth  year  the  rate 
for  males  is  double  that  for  females.  In  the  second,  sixth,  and  seventh  decades 
and  over  80  years  the  chances  of  dying  of  cardiac  disease  is  considerably  less 
for  males  than  for  females,  but  in  the  remaining  decades  the  advantage  is 
with  the  females.  For  this  particular  year  the  rates  for  all  ages  for  these  sepa¬ 
rate  categories  were:  Whole  population,  186;  total  whites,  169;  white  males, 
165;  white  females,  174;  total  negroes,  282;  negro  males,  302;  negro  females, 
260.  Thus,  the  rates  were  considerably  higher  in  negroes  than  in  whites,  and 
somewhat  higher  in  white  females  than  in  white  males  and  in  negro  males 
than  in  negro  females. 

It  is  evident  that  variations  in  the  proportion  of  the  population  over  30 
years  of  age  and  in  the  ratios  of  whites  to  negroes  and  of  males  to  females 
must  have  very  materially  influenced  the  course  of  the  mortality  from  cardiac 
disease.  Changes  in  the  age  distribution  of  the  population  can  not  have 
exerted  any  marked  influence  upon  the  recorded  mortality-rates  since  1830, 
for,  when  these  rates  are  corrected  for  this  factor,  it  appears  that  not  more 
than  5  per  cent  of  the  advance  can  be  so  explained. 

In  table  101  the  course  of  the  annual  mortality-rates  for  the  rubrics  apo¬ 
plexy  and  softening  of  the  brain  may  be  followed.  Studying  the  combined 
rates,  and  omitting  from  consideration  the  figures  for  1816  (which  are  given 
under  the  heading  apoplexy)  as  subject  to  large  error,  it  will  be  observed  that 
the  rate  rose  with  some  fluctuations  from  the  very  low  level  of  5  in  1813  to 
40  by  1821.  During  the  next  30  years  the  rate  varied  from  4  in  1826  to  36 
in  1833,  and  in  1845  stood  at  11.  Between  1846  and  1874  there  was  no  con¬ 
siderable  rise  in  the  rates,  but  the  annual  variation  became  less  marked.  As 
the  rates  jumped  from  34  in  1874  to  79  in  1875,  and  as  after  this  date  never 
but  once  (1909)  fell  below  60,  it  would  appear  that  the  rates  were  affected 
considerably  by  the  introduction  of  death  certificates  in  the  latter  year.  With 
exceptionally  high  rates  in  only  a  few  years  (85  in  1893,  93  in  1895,  91  in 
1913,  and  86  in  1914),  there  was  remarkably  little  change  in  the  rates  between 
1875  and  1915.  Rising  abruptly  to  109  in  1915,  the  rate  reached  the  unusually 
high  level  of  135  by  1918,  to  fall  to  112  by  1920. 

Passing  now  to  rates  averaged  for  5-year  periods  (table  110),  it  will  be 
noted  that  the  rate,  after  rising  abruptly  from  10  for  1812-1815  to  38  for 
1816-1820,  fluctuated  between  16  as  the  lowest  and  42  as  the  highest  for  any 
quinquennial  period  until  1875.  The  course  of  the  rates  during  these  60  years 
is  marked  by  instability.  Having  risen  to  70  for  the  5  years  1876-1880,  and 
retained  this  level  for  the  succeeding  quinquennium,  the  rates  rose  to  78  between 
1886  and  1890,  and  to  82  between  1891  and  1895.  During  the  next  15  years 
there  was  a  gradual  recession,  and  for  the  quinquennium  1906-1910,  the  rate 
stood  at  66.  During  the  period  1911-1915,  though  there  was  an  upward  turn 
to  86,  the  rate  was  not  markedly  above  the  highest  previous  level.  The  rise 
during  the  next  quinquennium  to  120,  due  largely  but  by  no  means  entirely 
to  the  excessively  high  rates  of  135  in  1918,  the  year  of  the  great  influenza 
epidemic,  showed  not  only  a  marked  increase  over  the  period  immediately 
preceding,  but  well  nigh  a  doubling  in  the  rate  within  10  years. 

As  measured  by  the  experience  of  1920  (table  112),  the  mortality-rates  for 
this  rubric  were  decidedly  higher  for  negroes  than  for  whites,  and  for  males 
than  for  females  in  both  races.  The  influence  of  age  is  conspicuous.  The  rates 
30 


460  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

are  negligible  below  the  thirtieth  year  both  in  whites  and  in  negroes,  and 
relatively  insignificant  in  whites  until  the  fifth  decade  of  life.  Among  the 
whites  the  greater  mortality  in  females  over  males  occurs  in  all  the  age  dis¬ 
tributions  below  the  sixtieth  year,  and  after  this  age  the  advantage  is  slightly 
with  the  female,  except  between  70  and  80.  Among  negroes  the  mortality  is 
markedly  higher  in  females  than  in  males  for  each  age-group  below  the 
eightieth  year.  Not  until  extreme  old  age — 80  years  and  over — do  the  rates 
for  negroes  fall  below  those  for  whites. 

The  rates  for  renal  disease,  exclusive  of  tumors  and  as  previously  qualified, 
averaged  for  5-year  periods,  are  given  in  table  110.  It  is  evident  that  until 
1890,  at  least,  these  rates  measure  rather  the  degree  of  the  recognition  than 


Table  112. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants, 
from  apoplexy,  according  to  age,  color,  and  sex,  for  1920  * 


D  =  death.  R  =  rate. 


Age-period- 

Total. 

White. 

Colored . 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fern. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

Under  1  year . 

1  to  4  years . 

.... 

5  to  9  years . 

.... 

0  to  9  years . 

10  to  19  years . 

1 

1 

1 

6 

•  .•  • 

•  •  •  • 

1 

11 

20  to  29  years . 

3 

2 

3 

3 

3 

5 

30  to  39  years . 

25 

20 

11 

11 

4 

8 

7 

14 

14 

64 

5 

45 

9 

84 

40  to  49  years . 

75 

81 

38 

50 

18 

47 

20 

52 

37 

238 

15 

181 

22 

302 

50  to  59  years . 

156 

249 

106 

194 

49 

184 

57 

203 

50 

636 

20 

471 

30 

830 

60  to  69  years . 

244 

678 

201 

618 

104 

679 

97 

563 

43 

1244 

17 

992 

26 

1484 

70  to  79  years . 

224 

1554 

205 

1570 

88 

1572 

117 

1568 

19 

1401 

6 

992 

13 

1731 

80  years  and  over . . 

92 

2644 

83 

2655 

30 

2671 

53 

2646 

9 

2542 

4 

2985 

5 

2273 

Total  . 

820 

112 

647 

104 

296 

96 

351 

111 

173 

159 

67 

126 

106 

191 

*  This  distribution  of  deaths  does  not  include  the  3  recorded  under  softening  of  the 
brain  for  this  year. 


the  lethal  force  of  kidney  affections.  Not  until  after  1855  did  the  rate  for 
kidney  disease  as  a  whole  equal  the  rate  of  5  in  1920  for  renal  affections  other 
than  Bright’s  disease,  and  as  late  as  1871-1875  the  rate  was  only  15.  By  a 
steady  rise  the  rate  increased  by  300  per  cent  during  the  succeeding  15  years 
and  for  the  period  1886-1890  was  60.  Having  advanced  from  88  for  1891- 
1895  to  143  for  1901-1905,  during  the  next  15  years  the  average  rate  for 
Bright’s  disease  scarcely  varied  from  170.  Since  1901,  deaths  from  acute  and 
chronic  nephritis  have  been  recorded  separately.  From  the  averaged  rates  for 
these  two  rubrics,  it  appears  that  for  the  first  2  and  the  last  of  the  4  quin¬ 
quennial  period  the  rates  for  acute  Bright’s  disease  did  not  vary  far  from  12, 
while  for  the  third  period  they  were  double  this  figure.  The  fluctuations  in 
the  rates  for  chronic  nephritis  since  1905  have  been  comparatively  slight. 
Using  the  data  for  1920  for  comparison  (table  113),  it  appears  that  while  the 
rate  was  about  one-half  higher  in  the  negro  than  the  white  population,  there 


VARIOUS  CHRONIC  ORGANIC  DISEASES 


46J 


was  no  considerable  difference  in  the  mortality  for  the  two  sexes  of  either  race. 
The  influence  of  age,  however,  was  very  marked.  For  the  whole  population 
mortality  rates  were  negligible  in  the  first  decade  and  in  the  second  decade  the 
rates  for  each  category  were  uniformly  relatively  low.  From  the  twentieth 
to  the  eightieth  year  the  rate  for  each  decade  of  life  was  more  than  double  that 
for  the  age-period  immediately  preceding,  the  actual  increase  being  from  25 
in  the  third  to  1,741  in  the  eighth  decade.  In  the  age-group  80  and  over  the 
mortality  was  2,874.  While  this  same  ratio  of  increase  obtained  for  whites, 
the  progress  of  mortality  through  the  decades  of  life  was  somewhat  different 
for  negroes,  among  whom  it  was  not  maintained  during  the  seventh  and  eighth 
decades.  In  whites,  as  between  the  sexes,  the  rates  were  uniformly  higher  in 

‘Table  113. — Number  of  deaths  and  rate  of  death ,  per  100,000  living  inhabitants,  from 

nephritis,  according  to  age,  color,  and  sex,  for  1920. 


D  =  death.  R  =  rate. 


rT^v4-  r.  1 

White. 

Colored. 

a1* 

Age-period. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

Under  1  year . 

2 

13 

1 

8 

1 

15 

.  .  . 

•  •  •  • 

1 

51 

1 

99 

1  to  4  years . 

1 

2 

1 

2 

•  •  • 

•  •  •  • 

1 

4 

5  to  9  years . 

1 

2 

1 

2 

1 

4 

0  to  9  years . 

4 

3 

3 

3 

2 

3 

1 

2 

1 

6 

1 

12 

10  to  19  years . 

12 

10 

11 

9 

6 

11 

5 

9 

1 

6 

1 

11 

20  to  29  years . 

36 

25 

22 

18 

11 

19 

11 

18 

14 

54 

10 

82 

4 

29 

30  to  39  years . 

67 

55 

44 

44 

28 

56 

16 

32 

23 

105 

12 

109 

11 

102 

40  to  49  years . 

127 

138 

81 

106 

37 

97 

44 

114 

46 

295 

17 

205 

29 

398 

50  to  59  years . 

225 

360 

162 

296 

90 

337 

72 

257 

63 

802 

34 

801 

29 

803 

60  to  69  years . 

269 

747 

223 

685 

123 

804 

100 

580 

46 

1331 

21 

1226 

25 

1427 

70  to  79  years . 

251 

1741 

226 

1731 

110 

1965 

116 

1555 

25 

1844 

14 

2314 

11 

1465 

80  years  and  over. . 

100 

2874 

89 

2847 

41 

3651 

48 

2396 

11 

3107 

4 

2935 

7 

3182 

Total  . 

1091 

149 

861 

138 

448 

145 

413 

130 

230 

212 

112 

210 

118 

213 

males  than  in  females,  except  in  the  fifth  decade  of  life.  In  negroes,  the  rates 
for  males  were  higher  than  those  for  females  only  in  the  fifth,  sixth,  and 
seventh  decades  and  in  the  age-group  80  years  and  over.  On  the  whole,  the 
variations  in  mortality  between  the  sexes  in  respect  of  the  different  age-groups 
were  less  marked  in  the  black  than  in  the  white  race. 

With  average  rates  not  over  3  for  the  4  quinquennial  periods  between  1876 
and  1895,  the  mortality  ascribed  to  arterial  disease  (table  110)  reached  9 
between  1896  and  1900,  and  22  between  1901  and  1905.  Rising  slightly  to  24 
for  the  next  5-year  period,  the  rates  advanced  to  38  between  1911  and  1915 
and  fell  to  25  between  1916  and  1920.  Using  the  year  1920  as  a  criterion 
(table  114),  it  is  observed  that  while  the  rates  were  nearly  twice  as  great  in 
whites  as  in  negroes,  there  was  little  or  no  difference  in  the  rates  for  the  two 
sexes  of  these  races.  In  regard  to  age,  no  deaths  were  recorded  in  whites  below 
the  fortieth  year,  and  the  mortality  was  slight  below  the  sixtieth  year.  In 
negroes,  on  the  other  hand,  there  were  no  deaths  before  the  sixtieth  year  of 
age.  The  rates  were  higher  for  females  than  for  males  only  in  the  eighth 


462 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


decade  of  life  among  whites.  Higher  rates  for  males  than  for  females  occurred 
among  negroes  in  the  seventh  decade  and  after  the  eightieth  year.  The  com¬ 
paratively  low  death-rate  for  the  whole  population,  and  the  occurrence  of 
recorded  deaths  only  in  the  high  age-ranges,  suggest  that  deaths  certified  as 
due  to  arterio-sclerosis  in  Baltimore  were  associated  chiefly  with  the  senile 
type  of  the  disease.  It  is  well  established  among  pathological  anatomists  that 
diffuse  or  general  arterio-sclerosis  of  the  Gull  and  Sutton  type  is  common, 
especially  among  white  and  negro  males  between  the  forty-fifth  and  the 
sixtieth  years. 

The  mortality-rates  from  general  dropsy  (table  110)  followed  an  entirely 
different  course  from  those  for  the  other  rubrics  under  consideration.  Though 
there  were  occasional  fluctuations,  the  course  of  mortality  between  1812-1815 
and  1916-1920  was  generally  downward.  Rates  over  60  were  attained  in  8 
quinquennial  periods,  in  2  of  which  the  rates  were  over  80.  The  decline 


Table  114. — Number  of  deaths  and  rate  of  death ,  per  100,000  living  inhabitants,  from 
arterio-sclerosis,  according  to  age,  color,  and  sex,  for  1920. 

D  =  death.  R  =  rate. 


Age-periocL 

Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

i 

R 

D 

R 

D 

R 

D 

R 

1  to  39  years . 

j 

40  to  49  years . 

2 

2 

2 

3 

1 

3 

1 

3 

50  to  59  years . 

5 

8 

5 

9 

3 

11 

2 

7 

60  to  69  years . 

29 

81 

24 

74 

16 

105 

8 

46 

5 

144 

3 

175 

2 

114 

70  to  79  years . 

40 

278 

37 

283 

10 

179 

27 

362 

3 

221 

1 

165 

2 

266 

80  years  and  over. 

39 

1121 

37 

1184 

19 

1692 

18 

899 

2 

565 

1 

746 

1 

455 

Total  . 

115 

16 

105 

17 

49 

16 

56 

18 

10 

9 

5 

9 

5 

9 

after  1876,  during  the  period  in  which  the  increase  for  the  other  rubrics  was 
greatest,  is  very  striking. 

In  the  period  under  review  the  mortality-rates  from  three  of  these  rubrics, 
heart  disease,  nephritis,  and  arterial  disease  (arterio-sclerosis  and  apoplexy), 
have  increased.  The  rate  of  increase,  while  not  steady  and  unbroken  for  any 
one,  has  been  great — in  the  case  of  the  heart  disease  by  over  6,000  per  cent. 
The  mortality-rate  for  dropsy,  on  the  other  hand,  has  undergone  a  decrease, 
which  since  1870  has  been  notable.  In  how  far  are  these  changes  real  and 
dependent  upon  actual  modifications  in  the  lethal  force  of  diseases  of  these 
organs?  To  what  degree  are  they  apparent  and  to  be  explained  by  advance¬ 
ment  in  medical  knowledge,  especially  in  pathology  and  in  methods  of  pre¬ 
cision  in  diagnosis,  and  by  changes  in  classification  of  causes  of  death?  It  is 
impossible  to  answer  these  questions  with  exactness,  but  several  lines  of 
inquiry  offer  promise  of  partial  explanations. 

Owing  to  the  definite  objective  character  of  the  clinical  symptoms  in  average 
cases  and  early  knowledge  of  its  pathology,  apoplexy  was  the  first  of  these 
causes  of  death  in  which  diagnosis  may  be  expected  to  have  been  made  with 


VARIOUS  CHRONIC  ORGANIC  DISEASES 


463 


comparative  readiness  and  certainty.  The  classification  of  deaths  from  typical 
apoplectic  stroke  was  never  in  this  period  subject  to  confusion.  While  it  is 
quite  possible  that  some  deaths  properly  belonging  under  this  rubric  may 
have  been  classified  under  paralysis,  the  course  of  recorded  mortality  from 
that  cause  (table  117)  does  not  suggest  that  this  was  done  in  any  large  pro¬ 
portion  of  instances.  More  likely,  some  deaths  in  the  aged  following  remotely 
upon  apoplexy  may  have  been  classified  under  senility  or  under  causes  un¬ 
known.  The  evidence  at  hand  suggests  very  strongly  that  the  trend  of  the 
recorded  data  concerning  apoplexy  reflects  with  a  moderate  degree  of  accuracy 
the  actual  course  of  the  lethal  force  of  the  diseases  of  the  cerebral  vessels 
upon  which  the  clinical  picture  of  this  affection  is  founded. 

While  the  importance  of  aneurism  and  of  sclerosis,  or  atheroma  as  it  was 
commonly  called,  of  the  arteries  of  certain  organs,  those  of  the  heart  and 
brain  in  particular,  and  the  frequent  occurrence  of  pipestem-like  thickening 
with  calcification  of  superficial  arteries  in  the  aged  had  long  been  recognized, 
it  was  not  until  after  the  work  of  Gull  and  Sutton  in  1872  that  general 
arterio-sclerosis  gained  admission  to  medical  nosology.  Its  importance  as  one 
of  the  most,  or  indeed  the  most,  common  and  serious  disease  of  the  vascular 
system  was  first  called  to  the  attention  of  the  local  medical  profession  in 
1890  by  Osier,  who  recognized  it  clinically,  and  by  Welch,  Councilman,  and 
the  writer,  who  studied  it  at  autopsy.  Ten  years  elapsed  before  these  teach¬ 
ings  were  seriously  reflected  in  the  mortality-rate  for  arterial  disease.  Owing 
to  the  fact  that  so  many  of  the  objective  and  subjective  symptoms  of  the 
disease  center  about  the  heart,  which  in  so  many  cases  breaks  down  under  its 
burden,  many  of  the  deaths  of  individuals  in  whom  arterio-sclerosis  is  the 
primary  affection  are  returned  as  due  to  primary  disease  of  the  heart.  This 
was  especially  the  case  when  heart  hypertrophy,  of  which  arterio-sclerosis  is 
the  most  common  cause  after  the  fortieth  or  fiftieth  year,  was  regarded  as  a 
primary  disease  rather  than  a  compensatory  adaptation.  On  account  of  the 
renal  disease  which  usually  but  not  necessarily  attends  arterio-sclerosis,  a  not 
inconsiderable  proportion  of  deaths  that  should  be  ascribed  to  the  latter  are 
yet  credited  by  physicians  to  the  former  disease.  As  the  great  mass  of  instances 
of  cerebral  hemorrhage  or  apoplexy  and  of  angina  pectoris  are  due  to  arterio¬ 
sclerosis,  and  as  many  deaths  from  general  arterio-sclerosis  have  been  certified 
and  classified  under  cardiac  and  renal  disease,  it  is  clear  that  the  official  figures 
for  arterio-sclerosis  fall  far  short  of  actual  occurrence.  The  mortality  from 
general  arterio-sclerosis,  whatever  it  was  before  1900,  was  probably  hidden 
partly  in  renal  but  chiefly  in  cardiac  diseases.  This  affection  in  typical  form 
was  very  common  in  1890,  when  it  was  first  recognized  in  Baltimore.  All  the 
evidence  at  hand  supports  the  opinion  that  it  was  by  no  means  a  new  disease, 
but  only  a  common  disease  newly  recognized.  It  would  appear  that  there  has 
been  no  significant  change  in  the  rate  of  its  recognition  since  1900.  It  has 
been  pointed  out  in  the  discussion  of  the  age  distribution  of  deaths  classified 
under  arterial  disease  that  deaths  certified  as  due  to  arterio-sclerosis  by  phy¬ 
sicians  must  be  confined  largely  to  the  senile  type. 

Until  1895,  the  mortality  figures  measure  the  degree  of  recognition  rather 
than  the  lethal  force  of  kidney  disease,  for  even  allowing  for  differences  in 
the  age  distribution  of  the  population,  unless  the  mortality  increased  in  ratios 
that  stagger  the  imagination,  the  picture  presented  by  these  figures  can  not 


464  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

truly  represent  actual  occurrence.  The  mortality-rates  for  renal  disease  did 
not  reach  15  until  the  quinquennium  1871-1875,  half  a  century  after  Richard 
Bright’s  first  contributions  to  the  pathology  of  the  kidney  affections  identified 
with  his  name  and  a  quarter  of  a  century  after  Charles  Frick  had  impressed 
upon  his  Baltimore  colleagues  the  importance  of  the  use  of  chemical  methods, 
and  when  Christopher  Johnson,  sr.,  was  using  microscopical  methods  of  uri¬ 
nary  examination.  By  1890  there  could  have  been  few  physicians  unfamiliar 
with  the  clinical  course  of  Bright’s  disease,  but,  nevertheless,  within  the  next 
10  years  the  mortality-rate  doubled,  and  continued  to  rise  until  1906.  It  may 
well  be  that  the  failure  of  the  rate  for  nephritis  to  rise  between  1906  and  1920 
was  due  to  the  assignment  of  some  of  the  deaths  which  would  otherwise  have 
been  classified  under  this  rubric  to  arterio-sclerosis,  and  that  during  this 
period  the  balance  of  the  rates  as  between  these  two  rubrics  became  stabilized. 

While  the  older  physicians  were  careful  observers  and  possessed  many 
criteria,  such  as  the  character  of  the  pulse,  shortness  of  breath,  pain  in  the 
region  of  the  heart,  evidences  of  engorgement  of  the  lungs,  blueness  of  the  skin, 
and  the  like,  upon  which  to  base  diagnosis  of  heart  disease,  the  use  of  refined 
methods  is  nowhere  more  necessary  for  accuracy  than  in  the  field  of  cardiac 
disease.  It  was  pointed  out  in  another  section  that  previous  to  1890  no  large 
proportion  of  Baltimore  physicians  had  had  opportunity  for  accurate  train¬ 
ing  in  palpitation,  percussion,  and  auscultation  of  the  chest.  The  more  recently 
introduced  instruments  of  precision,  the  blood-pressure  gauge  and  the  electro¬ 
cardiogram,  must  have  tended  to  augment  appreciably  the  proportion  of  deaths 
ascribed  to  cardiac  disease.  On  the  whole,  during  the  past  30  years  many 
events  have  conspired  to  increase  the  mortality-rates  for  heart  and  kidney 
diseases  and  general  arterio-sclerosis  by  increasing  precision  in  diagnosis.  It 
is  evident  from  the  tables  that  at  least  some  of  the  increase  in  the  rates  for 
these  three  rubrics,  organic  heart  disease,  arterio-sclerosis,  and  nephritis,  has 
been  at  the  expense  of  the  rubric  dropsy,  which  has  declined  as  the  others  have 
risen.  This  is  not  surprising,  because  the  affections  included  under  these 
rubrics  embrace  all  the  pathological  states  responsible  in  significant  degree 
for  general  dropsy.  Therefore,  while  the  deaths  ascribed  to  dropsy  can  not  be 
apportioned  correctly  among  the  other  three  rubrics,  it  follows  that  the  sum 
of  the  rates  for  the  four  rubrics  must  express  with  some  degree  of  nearness 
actual  observed  experience  for  the  group  as  a  whole.  When  this  was  done 
(table  110),  the  combined  rate  fell  steadily  from  82  for  1812-1815  to  41  for 
1831-1835,  and  then  rose  during  the  following  20  years  to  114  for  1851-1855, 
a  rate  maintained  for  15  years.  Between  1866  and  1880,  the  rate  fluctuated 
between  137  and  145.  After  1880,  when  the  rate  for  dropsy  had  become 
insignificant,  the  rates  for  this  group  continued  to  ascend  uninterruptedly, 
but  by  unequal  steps,  to  388  for  the  period  1916-1920.  The  relatively  slight 
changes  in  the  combined  rate  for  these  affections  between  1906  and  1920  was 
associated  with  stabilized  rates  for  arterio-sclerosis  and  nephritis  and  with 
ascending  rates  for  cardiac  disease.  Whatever  the  explanation  may  be,  the 
rates  for  this  group,  as  judged  from  the  officially  recorded  figures,  fell  by 
50  per  cent  between  1812  and  1835,  but  by  1850  had  surpassed  the  former  high 
level.  When  the  course  of  the  rates  for  this  group  is  compared  with  that  of  the 
rates  for  senility  and  causes  unknown  in  adults  (table  110)  in  the  earlier 
years,  in  general  the  rates  for  the  latter  were  high  or  indeed  often  rising  when 


VARIOUS  CHRONIC  ORGANIC  DISEASES 


465 


the  former  were  falling  or  at  least  low.  During  the  period  of  increase  in  pre¬ 
cision  of  diagnosis  between  1880  and  1905  the  rates  for  senility  and  for  causes 
unknown  fell,  while  those  for  the  cardio-vascular-renal  group  rose.  Although 
the  assumption  that  all  the  deaths  classified  under  the  rubrics  senility  and 
causes  unknown  in  adults  should  have  been  assigned  to  cardio-vascular-renal 
diseases  is  by  no  means  warranted,  it  is  probable  that  a  very  large  moiety  of 
the  number  properly  belonged  under  those  rubrics.  Since  1905,  while  precision 
of  diagnosis  in  this  group  of  diseases  has  probably  advanced  but  slightly,  but 
classification  of  the  certified  causes  of  death  has  become  more  exact,  the  rates 
for  senility  and  causes  unknown  have  fallen  to  negligible  levels  and  the  mor¬ 
tality  for  cardiac,  renal,  and  arterial  disease  (exclusive  of  apoplexy)  taken 
together  has  become  more  stable  (column  5,  table  110).  It  is  reasonable  to  sup¬ 
pose  that  some  of  the  increase  in  the  recorded  mortality  from  these  diseases 
is  dependent  upon  changes  in  the  age  distribution  of  the  population  resulting 
in  a  gradual  increase  in  the  proportion  of  persons  in  the  age-groups  in  which 
their  force  of  mortality  is  naturally  high.  However,  rates  corrected  for  age 
indicate  that  between  1830  and  1920  for  heart  disease  less  than  5  per  cent, 
and  for  apoplexy  less  than  30  per  cent,  of  the  rise  in  rates  can  be  explained 
by  this  factor. 

When  the  rates  for  apoplexy  are  combined  with  those  for  cardiac  and  renal 
diseases  and  for  arterio-sclerosis  and  dropsy  (column  7,  table  110),  until 
1870  the  shape  of  the  curve  is  very  close  to  that  of  the  total  rates  for  the  other 
numbers  of  the  group  without  apoplexy  (column  5,  table  110).  After  1870, 
the  ascent  in  the  curve  for  the  former  is  much  steeper  and  smoother  than  that 
for  the  latter.  The  sum  of  the  rates  for  the  five  rubrics,  heart,  renal,  and 
arterial  disease,  dropsy,  and  apoplexy,  must  be  taken  as  measuring  the  course 
of  the  lethal  force  of  cardio-vascular-renal  affections  as  indicated  by  the  official 
records.  Thus  viewed  (column  7,  table  110,  graph  28),  the  mortality-rate 
which  stood  at  92  between  1812  and  1815  and  rose  to  109  between  1816  and 
1820,  fell  almost  unbrokenly  during  the  succeeding  25  years  to  73  between 
1841  and  1845.  In  the  next  quinquennium  the  rate  approached  closely  its 
previous  highest  level,  and  from  1851  to  1865  it  varied  between  132  and  139. 
Between  1866  and  1895  the  rate  more  than  doubled.  By  steady  progression 
it  rose  from  332  for  1896-1900  to  508  for  the  quinquennium  ending  in  1920. 
Thus  measured  it  appears,  then,  that  the  recorded  mortality  from  this  group 
of  affections  increased  by  over  450  per  cent  between  1812  and  1815  and  1916 
and  1920. 

For  the  years  1918-1920,  inclusive,  data  are  available  for  estimating  the 
influence  of  race  and  sex  upon  mortality  from  these  four  rubrics.  Bates 
specific  for  these  attributes  are  presented  in  table  115.  Taking  the  rates 
averaged  for  the  three  years,  it  will  be  noted  that  for  each  rubric  except 
arterio-sclerosis  the  rates  are  higher  in  negroes  than  in  whites,  and  that  among 
the  latter  there  are  no  significant  differences  in  the  rates  for  the  two  sexes 
in  any  of  the  rubrics.  Among  negroes  the  rates  were  significantly  higher  in 
males  for  heart  disease  and  in  females  for  apoplexy.  The  total  averaged  rates 
for  the  four  rubrics  taken  together  were  510  for  the  whole  population,  470  and 
741  for  whites  and  negroes,  465  and  471  for  male  and  female  whites,  and  739 
and  742  for  male  and  female  negroes,  respectively. 


466  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


This  extraordinary  rise  in  the  rates  for  this  group  of  diseases  in  the  more 
than  100  years  under  review  is  satisfactorily  explained  neither  by  errors  of 
diagnosis  and  faults  of  statistical  classification,  nor  by  changes  in  the  age  and 
race  groupings  of  the  population.  It  has  been  found  that  when  all  the  deaths 
attributed  to  senility  and  causes  unknown  in  adults — the  only  two  rubrics 
available  for  hiding  in  earlier  years  any  considerable  proportion  of  deaths 
due  to  the  group  of  cardio-vascular-renal  disease  now  under  consideration — 
are  by  the  most  liberal  interpretation  assigned  to  the  latter  group,  the  balance 
remains  far  from  equal.  Assuming  that  the  changes  in  the  age  distribution 
of  the  population  exerted  the  same  influence  upon  the  rates  for  nephritis, 


Table  115. — Number  of  deaths  and  rate  of  death,  'per  100,000  living  inhabitants,  from  organic 
diseases  of  the  heart,  softening  of  the  brain  and  apoplexy,  nephritis,  and  arteriosclerosis, 
according  to  color  and  sex,  for  1918,  1919,  and  1920,  with  their  respective  averaged  rates 
for  the  8-year  period  1918-1920. 


D  =  death.  R  =  rate. 


Disease. 

Year. 

Total. 

White. 

Colored. 

Total- 

Male. 

Fem. 

To'al. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

f 1918  . 

1533 

248 

1128 

217 

585 

228 

543 

207 

405 

409 

194 

428 

211 

393 

ui  game 

1919  . 

1270 

176 

967 

157 

471 

153 

496 

160 

303 

291 

158 

330 

145 

257 

diseases  oi 

1920  . 

1366 

186 

1061 

170 

510 

165 

551 

174 

305 

282 

161 

302 

144 

260 

me  Heart 

Average  .  . . 

•  •  •  • 

203 

«  •  •  • 

181 

. . . 

182 

•  •  • 

181 

•  •  • 

327 

•  •  • 

354 

•  •  • 

303 

Softening 

f 1918  . 

835 

135 

652 

126 

302 

118 

350 

134 

183 

185 

69 

152 

114 

212 

of  the 

j  1919  . 

838 

116 

676 

110 

316 

103 

360 

116 

162 

155 

60 

125 

102 

181 

brain  and 

1920  . 

823 

112 

650 

104 

297 

96 

353 

111 

173 

159 

67 

126 

106 

191 

apoplexy 

Average  . . . 

.... 

121 

.... 

113 

•  •  • 

106 

. . . 

120 

•  •  • 

166 

•  •  • 

134 

•  •  • 

195 

f 1918  . 

1150 

186 

888 

171 

466 

181 

422 

161 

262 

265 

126 

278 

136 

253 

Nephritis 

1919  . 

1137 

158 

903 

146 

434 

141 

469 

151 

234 

224 

107 

224 

127 

225 

1920  . 

1091 

149 

861 

138 

448 

145 

413 

130 

230 

212 

112 

210 

118 

213 

Average  . . . 

«  •  •  • 

164 

.... 

152 

, . . 

156 

•  •  • 

148 

•  •  • 

234 

•  •  • 

237 

•  •  • 

230 

fl918  . 

169 

27 

152 

29 

82 

32 

70 

27 

17 

17 

10 

22 

7 

13 

Arterio- 

1919  . 

144 

20 

129 

21 

57 

19 

72 

23 

15 

14 

5 

10 

10 

18 

sclerosis 

1920  . 

115 

16 

105 

17 

49 

16 

56 

18 

10 

9 

5 

9 

5 

9 

Average  . . . 

•  •  •  • 

21 

•  •  •  • 

22 

•  •  • 

22 

. . . 

23 

•  •  • 

14 

•  •  • 

14 

•  •  • 

13 

arterio-sclerosis,  and  dropsy  as  for  heart  disease  and  for  apoplexy,  a  large  gap 
yet  remains  to  be  filled.  During  the  period  of  rising  rates,  the  negro,  with  his 
conspicuously  higher  death-rates  from  this  group  of  diseases,  has  steadily 
decreased  in  numerical  proportion  to  the  white  in  the  population.  In  regard 
to  the  possible  influence  of  sex,  there  has  been  no  considerable  variation  in 
the  proportion  of  males  and  females  in  the  population.  All  things  measurable 
considered,  the  conclusions  seems  inevitable  that  since  1870  there  has  been  a 
progressive  but  gradual  actual  increase  in  the  mortality  from  cardio-vascular- 
renal  disease,  independent  of  changes  in  race  and  age  composition  of  the 
population. 

According  to  the  experience  of  1910  and  1920,  when  rates  specific  for  age 
may  be  calculated  with  a  reasonable  degree  of  accuracy,  the  mortality  from 


VARIOUS  CHRONIC  ORGANIC  DISEASES 


467 


cardio-vascular-renal  disease  was  limited  very  largely,  though  by  no  means 
entirely,  to  individuals  of  40  years  of  age  and  over.  It  has  been  shown  that 
since  1850,  at  least,  this  age  group  of  the  population  has  increased  very  con¬ 
siderably  in  its  proportional  relations  to  the  whole.  Therefore,  rates  calcu¬ 
lated  from  the  combined  mortality  figures  for  all  these  rubrics  in  the  census 
years  1850  to  1920,  inclusive,  on  the  basis  populations  in  this  age-group  should 
be,  within  a  moderate  degree  of  error,  specific  for  age.  The  results  of  such  a 
calculation  are  presented  in  table  116  and  graph  29.  Judged  by  this  criterion, 
admittedly  lacking  in  absolute  exactness,  there  was  singularly  little  change  in 
the  rate  of  mortality  from  these  affections  between  1850  and  1870.  Between 
1870  and  1910  the  rate  ascended  by  regular  steps,  with  the  result  that  in  this 
period  the  mortality  was  nearly  doubled;  but  in  1920  the  rate  was  lower  than 
in  1890  and  but  little  higher  than  in  1880.  In  so  far  as  conclusions  may  be 
justified  from  these  premises,  in  which  no  allowances  are  made  for  the  infl- 
ence  of  such  important  factors  as  color  and  sex,  it  appears  that,  while  mortality 

Table  116. — Number  of  deaths  and  rate  of  death,  per  100,000 
living  inhabitants  over  J+0  years  of  age,  from  cardio-vas- 
cular-renal  diseases,  for  the  decennia  1830  to  1920,  inclu¬ 
sive, * 


D  =  death.  R  =  rate. 


Year. 

D 

R 

Year. 

D 

R 

1830  .  . 

63 

278 

1880  .. 

737 

958 

1840  . . 

96 

601 

1890  . . 

1184 

1141 

1850  . . 

225 

777 

1900  . . 

1783 

1413 

1860  . . 

285 

712 

1910  . . 

2511 

1656 

1870  .. 

438 

780 

1920  . . 

2225 

1066 

*  The  number  of  deaths  for  each  decennium  is  a  3-year 
average  of  that  obtaining  in  the  decennial  year  and  in  those 
years  immediately  preceding  and  following,  except  in  1920,  when 
the  average  is  for  1919  and  1920  only. 

from  cardio-vascular-renal  disease  has  increased  considerably  since  1850,  the 
actual  increase  has  been  much  less  than  indicated  by  the  crude  rates.  In  fact, 
when  correction  is  made  for  age  in  this  in  some  respects  crude  fashion,  it  seems 
certain  that  mortality  from  this  group  of  causes  really  declined  between  1910 
and  1920  and  that  the  rate  was  actually  lower  in  1920  than  in  1890. 

Further  consideration  of  this  table  brings  to  light  two  facts  that  demand 
explanation.  The  rates  were  much  higher  in  1850  than  in  1860  and  consid¬ 
erably  lower  in  1920  than  in  1890,  although  they  rose  sharply  between  1840 
and  1850  and  steadily  between  1890  and  1910.  If  these  mortality-rates  possess 
any  significant  basis  of  trustworthiness,  some  more  reasonable  explanation 
than  changes  in  statistical  classification  is  necessary.  Here  is  a  compound 
group  of  chronic  organic  diseases  whose  mortality-rates  reasonably  specific 
for  age  run  a  course  similar  to  those  of  some  specific  infectious  disease.  In 
this  peculiarity  lies  a  plausible  partial  solution  of  the  mystery.  Many  statis¬ 
ticians,  of  whom  Bertillon  (64)  and  Pearl  (65)  are  to  be  especially  men¬ 
tioned  in  this  connection,  have  observed  that  one  of  the  most  conspicuous 
immediate  effects  of  epidemic  influenza  is  to  raise  the  mortality  from  the  group 


468  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

of  causes  here  grouped  under  cardiovascular  affections.  The  ascent  in  the 
rate  for  1850  corresponds  to  the  influenza  epidemic  of  1849-1850,  which  appar¬ 
ently  died  out  at  once,  without  becoming  endemic. .  Its  effects,  whatever  their 
other  characters,  were  sharp  and  transient,  and  therefore  made  no  permanent 
impression.  The  impact  of  the  pandemic  of  1890  was  associated  with  a  sharp 
rise  in  the  rate  for  cardio-vascular-renal  diseases,  which  was,  however,  not 
transient,  but  lasting.  The  mortality  continued  to  rise  through  the  next  two 
decennia  and  well  into  the  third  (through  1918).  But,  as  lias  been  shown  in 
the  discussion  of  influenza,  this  disease  also  changed  its  habit  and,  instead  of 
disappearing,  settled  into  endemicity.  It  may  well  be  that  in  each  year 
between  1891  and  1917  endemic  influenza  killed  off  a  certain  proportion  of 
the  susceptible  weaklings  among  the  cardio-vascular-renally  afflicted  popula¬ 
tion,  and  in  the  pandemic  of  1918  this  crop  was  harvested  in  even  greater 
numbers  than  usual.  The  sharp  decline  in  the  rate  for  cardio-vascular-renal 
affections  during  the  three  following  years  (reflected  in  the  rate  for  1920 
in  table  101),  while  influenza  continued  endemic,  would  be  explained  for  the 
same  reasons  by  the  unusually  heavy  losses  in  1918. 

The  chief  objections  to  this  argument  are:  (1)  The  mortality  from  these 
affections  rose  between  1861  and  1880,  in  a  period  without  influenza,  and 
(2)  if  endemic  influenza  operated  so  effectively  for  the  27  years  after  1890, 
long  before  the  expiration  of  this  time  it  should  have  so  seriously  depleted 
its  store  of  possible  victims,  that  the  rate  for  cardio-vascular-renal  diseases 
should  have  fallen  in  comparatively  few  years  to  much  lower  levels.  The  most 
ready  escape  from  this  dilemma  is  to  assume  that  a  very  large  part  in  the 
causation  of  this  disease-group,  or  at  least  of  its  most  prominent  member, 
heart  disease,  is  borne  by  the  common  communicable  diseases  (including 
influenza),  many  of  which  were  at  this  acme  in  the  seventh,  eighth,  and  ninth 
decennia  of  the  last  century,  and  that  since  their  decline  endemic  influenza 
has  in  a  large  measure  taken  on. this  role.  However  this  may  be,  it  seems  cer¬ 
tain  that  the  death-rate  of  cardio-vascular-renal  disease  has  been  determined, 
at  times  at  least,  in  some  significant  measure  by  influenza. 

The  general  biological  implications  of  the  effects  of  the  febrile  diseases  upon 
the  course  of  mortality  from  this  set  of  causes  will  be  considered  further 
under  the  discussion  changes  of  the  death-rate  from  all  causes. 


Chapter  XV. — Diseases  of  the  Central  Nervous 
System  and  Liver;  Diabetes;  Alcoholism. 

(Tables  117  to  119.) 

CHRONIC  DISEASES  OF  THE  CENTRAL  NERVOUS  SYSTEM. 

To  the  rubric  palsy,  later  changed  to  paralysis  in  1874  and  to  paralysis 
without  specified  cause  in  1899,  a  gradually  increasing  number  of  deaths  were 
credited  each  year  from  1812  to  1892  (table  117).  Since  the  latter  date,  with 
the  gradual  increase  in  the  proportional  allotment  of  deaths  from  diseases  of 
the  nervous  system  to  other  rubrics,  this  rubric  declined  in  relative  impor¬ 
tance,  and,  with  the  revision  of  the  international  classification  effective  in 
1910,  as  rubric  66,  sank  into  comparative  obscurity. 

In  order  of  their  entrance  into  the  statistical  nosology,  there  appeared  epi¬ 
lepsy  in  1827,  chorea  in  1837,  locomotor  ataxia  in  1878,  general  paralysis  of 
the  insane  in  1899,  other  diseases  of  the  spinal  cord  in  1902,  and  other  diseases 
of  the  nervous  system  in  1910.  It  is  to  be  presumed  that,  until  and  unless 
specifically  assigned  to  these  other  rubrics,  deaths  due  to  primary  diseases  of 
the  nervous  system  associated  with  paralysis  (and  this  excludes  of  course 
apoplexy,  hemorrhage,  congestion,  and  softening  or  mechanical  injury  of  the 
brain,  all  considered  elsewhere)  were  classified  under  the  original  rubric  palsy 
or  its  successor,  rubric  66. 

The  mortality-rates  for  these  rubrics,  separate  and  combined,  as  averaged 
for  quinquennial  periods,  are  presented  in  table  118.  As  it  is  not  possible  to 
follow  the  deaths  from  insanity  with  any  certainty,  they  have  been  left  out  of 
consideration.  It  will  be  noted  that  while  the  rates  for  chorea  varied  from 
time  to  time,  this  affection  has  not  been  an  important  cause  of  death.  The 
rates  for  epilepsy  assume  importance  only  after  1870,  and  since  this  date  they 
have  not  risen  above  4  nor  fallen  below  2.  Somewhat  lower  rates  have  pre¬ 
vailed  for  locomotor  ataxia  (1  to  3)  since  1880.  This  affection  reached 
its  highest  recorded  mortality  level  in  1901-1910.  The  rate  for  general  paraly¬ 
sis  rose  from  3  in  1901-1905  to  5  in  1906-1915,  but  during  the  last  quinquen¬ 
nium  fell  to  3.  The  decrease  in  the  rates  for  both  these  two  forms  of  syphilis 
of  the  nervous  system  during  the  period  1916-1920  was  due  to  the  fact  that 
owing  to  a  change  in  custom  of  classification  of  deaths  an  increasingly  large 
proportion  of  deaths  ascribed  to  them  have  been  classified  under  syphilis. 
During  the  10-year  period  1911-1920,  the  new  rubric,  other  diseases  of  the 
nervous  system  (number  74),  has  come  into  prominence  with  rates  of  5  and 
6  during  the  two  quinquennia. 

It  will  be  observed  that,  for  practical  purposes,  the  old  rubric  palsy  or 
paralysis  unspecified  held  the  ground  almost  unchallenged  during  the  nine¬ 
teenth  century,  and  that  only  since  1900,  with  the  full  differentiation  of  other 
rubrics,  has  it  receded  in  importance. 

Considering  this  group  of  affections  of  the  nervous  system  as  a  whole,  the 
quinquennial  rates  rose  from  15  for  1812-1815  to  21  during  the  following 
10  years.  Falling  during  a  period  of  20  years  after  1825  and  reaching  the 

469 


Table  117. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from  alcoholism,  chronic  diseases  of  the  central  nervous  system, 

diseases  of  the  liver  and  biliary  tract,  and  diabetes,  from  1812  to  1920,  inclusive. 


470 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


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Table  117. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhab  itants,  froin  alcoholism,  chronic  diseases  of  the  central  nervous  system, 

diseases  of  the  liver  and  biliary  tract, and  diabetes,  from  1812  to  1920,  inclusive. — Continued. 


472  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


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VARIOUS  CHRONIC  ORGANIC  DISEASES 


473 


level  of  13  for  the  quinquennium  1841-1845,  the  rate  rose  to  22  in  1846- 
1850,  and  remained  near  this  level  until  1860.  By  gradual  steps  the  averaged 
rate  ascended  during  the  next  35  years,  and  attained  its  highest  level,  58  in 
1891-1895.  From  this  level,  during  the  next  three  quinquennia,  the  rate 
declined  somewhat  gradually  to  44  in  1906-1910.  The  rate  fell  to  36  in  1911— 
1915  and  to  21  in  1916-1920.  The  very  distinct  rise  between  1860  and  1895 
in  the  mortality-rates  for  paralysis  is  difficult  to  explain.  It  is  not  possible 


Table  118. — Average  rate  of  death,  'per  100,000  living  inhabitants,  by  5-year  periods, 
from  alcoholism,  chronic  diseases  of  the  central  nervous  system,  diseases  of  the 
liver  and  biliary  tract,  and  diabetes,  from  1812  to  1920,  inclusive. 


Periods. 

Alcoholism. 

Chronic  diseases  of  the 

central  nervous  system. 

Diseases 
of  liver 
and  biliary 
tract. 

i 

Diabetes. 

Chorea- 

Epilepsy. 

Locomotor  ataxia. 

Other  diseases  of 
spinal  cord- 

General  paralysis. 

Other  diseases  of 
nervous  system. 

Paralysis  unspe¬ 

cified* 

Total. 

Cirrhosis  of  liver. 

Total. 

1812-15  . 

.... 

.... 

15 

15 

12 

1816-20  . 

53 

.... 

.... 

21 

21 

16 

•  •  •  • 

1821-25  . 

51 

•  •  *  • 

.... 

21 

21 

41 

•  •  •  • 

1826-30  . 

28 

•  •  •  • 

16 

17 

32 

•  •  •  • 

1831-35  . 

39 

•  •  •  • 

13 

13 

21 

•  •  •  • 

1836-40  . 

35 

0.53 

.... 

.... 

14 

15 

14 

•  •  •  • 

1841-45  . 

15 

0.16 

12 

13 

10 

•  •  •  • 

1846-50  . 

17 

•  •  •  • 

. 

22 

22 

5 

1851-55  . 

18 

0.12 

22 

22 

13 

1 

1856-60  . 

14 

0.10 

23 

23 

10 

1861-65  . 

8 

0.35 

28 

29 

9 

•  •  •  • 

1866-70  . 

2 

0.08 

1 

.... 

.... 

33 

34 

9 

•  •  •  • 

1871-75  . 

7 

0.48 

3 

.... 

.... 

38 

41 

14 

1 

1876-80  . 

9 

0.32 

4 

0.36 

.... 

38 

43 

8 

20 

2 

1881-85  . 

11 

0.33 

4 

1 

45 

50 

10 

23 

3 

1886-90  . 

9 

0.50 

4 

1 

47 

52 

12 

23 

4 

1891-95  . 

7 

0.21 

3 

2 

52 

58 

12 

22 

7 

1896-1900  . 

6 

0.44 

2 

2 

1 

42 

47 

12 

22 

8 

1901-05  . 

8 

0.26 

3 

3 

4 

3 

31 

45 

13 

23 

10 

1906-10  . 

9 

0.21 

3 

3 

5 

jr 

0 

1 

27 

44 

13 

23 

13 

1911-15  . 

8 

0.24 

3 

2 

5 

4 

5 

18 

36 

14 

21 

17 

1916-20  . 

4 

0.12 

2 

1 

4 

3 

6 

5 

21 

11 

19 

20 

to  arrive  at  a  completely  satisfactory  explanation  for  the  steady  rise  in  the 
mortality-rate  for  paralysis  in  the  period  before  the  rubrics  locomotor  ataxia, 
general  paralysis  (of  the  insane),  and  other  diseases  of  the  spinal  cord  and 
of  the  nervous  system  assumed  importance.  This  ascent  in  the  rate  may  have 
been  due  in  some  measure  to  the  possible  inclusion  of  deaths  that  should  have 
been  classified  under  congestion,  hemorrhage  and  softening  of  the  brain,  and 
insanity,  and  to  a  considerable  increase  in  the  prevalence  of  syphilis  or  of 
some  other  prominent  cause  or  causes  of  chronic  disease  of  the  central  nervous 
system.  The  decline  in  the  rates  for  the  rubric  (paralysis,  cause  unspecified) 
since  1896  is  accounted  for  partly  by  the  establishment  of  the  other  rubrics 
to  which  deaths  formerly  allotted  to  it  were  assigned,  and  partly  to  an  actual 
decrease  in  the  deaths  from  diseases  of  this  group.  Similarly,  the  marked 
decline  in  the  total  rate  since  1896,  may  be  attributed  to  more  careful  classi- 


474  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

fication  of  deaths,  to  more  general  and  adequate  treatment  of  syphilis,  and  to 
modifications  in  the  death-rates  from  other  diseases,  which  have  claimed  in 
more  recent  years  individuals  who  in  former  years  would  have  fallen  victims 
to  chronic  disorders  of  the  nervous  system.  It  appears  to  be  clear  that  to  no 
one  tangible  factor  can  be  credited  the  explanation  of  the  course  of  the 
mortality-rates  of  this  group  of  diseases  as  based  upon  officially  recorded 
deaths  during  the  more  than  100  years  under  review.  It  will  be  noted  that 
the  averaged  rates  between  1816  and  1825,  1846  and  1860,  were  at  the  same 
general  level  (21)  obtaining  in  1916-1920,  when  great  care  was  exercised  in 
the  accurate  classification  of  deaths. 

Rates  specific  for  age  and  color  for  1920  are  given  in  table  119.  In  all  cate¬ 
gories,  the  mortality  was  light  in  the  early  years  of  life  and  increased  with 
advancing  age.  In  negroes,  no  deaths  occurred  in  the  first  two  decades  of  life, 
and  in  every  age-group,  except  80  years  and  over,  the  mortality  was  decidedly 
less  than  among  whites.  For  all  ages,  the  rate  for  whites  was  double  that 
for  negroes. 

Since  1875,  at  least,  this  group  of  diseases  of  the  nervous  system  has  been 
studied  intensively  in  Baltimore,  first  by  F.  T.  Miles,  and  later  by  George 
Preston,  H.  J.  Berkley,  William  Osier,  H.  M.  Thomas,  and  others,  from  whom 
the  general  practitioner  has  had  large  opportunity  to  acquaint  himself  with 
their  recognition. 

DISEASES  OF  THE  LIVER. 

Under  one  heading  or  another,  deaths  from  affections  of  the  liver  (table 
117)  may  be  followed  continuously  since  1812.  Jaundice  persisted  as  a  sep¬ 
arate  rubric  from  1812  to  1898.  To  inflammation  of  the  liver  deaths  were 
attributed  in  most  years  between  1814  and  1897.  Other  rubrics  were  liver 
complaint,  from  1820  to  1874;  liver  abscess,  in  1821  and  1822  and  from  1878 
to  1898;  cirrhosis,  since  1875;  acute  yellow  atrophy  and  gall  stones,  since 
1878;  and  other  diseases  of  the  liver  since  1899.  The  sum  of  these  represents 
the  number  of  deaths  attributed  to  disease  of  the  liver,  cancer  excepted.  For 
various  reasons,  cirrhosis  of  the  liver  is  the  only  member  of  the  group  whose 
course  it  is  worth  while  to  follow  separately.  There  is  ample  reason  to  con¬ 
clude  that,  in  the  earlier  years  at  least,  the  officially  recorded  mortality  from 
liver  disease  has  fallen  short  of  actual  occurrence.  In  table  118  the  course 
of  the  force  of  recorded  mortality  from  diseases  of  the  liver  as  a  group  and 
for  cirrhosis  separately  may  be  followed  from  rates  averaged  for  quinquennial 
periods.  It  will  be  observed  that  the  rates  for  the  total  rose  from  12,  for  1812- 
1815,  to  16  during  the  succeeding  5  years,  and  ascended  abruptly  to  41,  the 
highest  level  attained*  in  1821-1825.  During  the  next  25  years  the  rate  steadily 
and  gradually  declined  to  5  during  the  quinquennium  1846-1850.  Between 
1851  and  1875  the  averaged  rate  did  not  exceed  14  nor  fall  below  9.  Coinci¬ 
dent  with  the  appearance  of  cirrhosis  of  the  liver  in  the  statistical  classifica¬ 
tion  in  1875,  the  rate  jumped  from  14  for  1870-1875  to  20  for  1876-1880. 
From  1881  there  was  remarkably  little  change  in  the  rate.  In  the  8  quinquen¬ 
nia  rates  of  23  obtained  in  4,  22  in  2,  and  21  and  19  in  one  each.  Similarly,  the 
rate  for  cirrhosis  of  the  liver  varied  within  narrow  limits  during  this  period. 
Starting  from  10  for  1881-1885  and  remaining  at  12  from  1886  to  1900,  and 
at  13  from  1901  to  1910,  the  averaged  rate  rose  to  14  in  1911-1915,  to  fall 
to  11  in  1916-1920.  The  stability  of  the  rate  for  this  affection  during  the 
40  years  is  striking. 


VARIOUS  CHRONIC  ORGANIC  DISEASES 


475 


It  is  evident  that  from  1876  to  1885  somewhat  less  and  after  1886  some¬ 
what  more  than  half  the  deaths  recorded  as  caused  by  disease  of  the  liver  and 
its  ducts  were  contributed  by  cirrhosis.  It  w'ould  seem  that  in  the  earlier  years 
this  affection,  when  recognized,  was  classified  largely  under  liver  complaint 
and  inflammation  of  the  liver,  and  that  before  its  establishment  as  a  separate 
rubric  it  must  have  been  either  of  less  common  occurrence  than  later,  was 
classified  elsewhere,  or  was  frequently  unrecognized.  It  appears  from  table 
119  in  which  are  given  the  rates  for  age  and  color  for  the  year  1920,  there  is 
but  little  difference  in  mortality  as  between  whites  and  negroes.  For  whites, 
with  an  insignificant  mortality  before  the  fortieth  year,  the  rate  advances 
steadily  to  its  highest  level  in  the  age-period  80  years  and  over.  Among 
negroes  there  were  no  deaths  before  the  fortieth  and  after  the  seventieth  years 
of  age,  and  the  highest  rate  occurred  in  the  seventh  decade  of  life. 

DIABETES. 

This  long-known  disease  was  not  recognized  in  the  local  statistical  nosology 
until  1847,  when  it  was  credited  with  1  death  (table  117).  It  appeared  again 

Table  119. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from  chronic 
diseases  of  the  central  nervous  system,  cirrhosis  of  the  liver,  and  diabetes,  according  to 
age  and  color,  for  1920. 

D  —  death.  R  =  rate. 


Age-periods. 

Diseases  of  central  nervous 
system. 

Cirrhosis  of  liver. 

Diabetes. 

Total. 

White. 

Colored. 

Total. 

White. 

Colored- 

Total. 

White. 

Colored. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

Under  1  year.... 

1  to  4  years .... 

i 

2 

1 

2 

1 

2 

1 

2 

5  to  9  years. . . . 

3 

5 

3 

5 

1 

2 

1 

2 

•  • 

0  to  9  years. . . . 

4 

3 

4 

3 

2 

1 

2 

2 

•  • 

10  to  19  years. . . . 

6 

5 

6 

6 

2 

2 

2 

2 

•  • 

20  to  29  years. . . . 

12 

8 

10 

8 

2 

8 

1 

1 

1 

1 

10 

7 

10 

8 

#  # 

30  to  39  years. . . . 

13 

11 

12 

12 

1 

5 

2 

2 

2 

2 

7 

6 

5 

5 

2 

9 

40  to  49  years. . . . 

18 

19 

17 

22 

1 

6 

10‘ 

11 

8 

10 

2 

13 

20 

22 

14 

18 

6 

39 

50  to  59  years. . . . 

18 

29 

17 

31 

1 

13 

12 

19 

9 

16 

3 

38 

40 

64 

36 

66 

4 

51 

60  to  69  years. . . . 

17 

47 

15 

46 

2 

58 

18 

50 

16 

49 

2 

58 

50 

139 

45 

138 

5 

145 

70  to  79  years. . . . 

19 

132 

18 

138 

1 

74 

8 

56 

8 

61 

•  * 

21 

146 

20 

153 

1 

74 

80  years  and  over 

8 

230 

7 

224 

1 

282 

2 

57 

2 

64 

3 

86 

3 

96 

•  • 

•  •  • 

Total  . 

115 

16 

106 

17 

9 

8 

53 

7 

46 

7 

7 

6 

155 

, 

21 

137 

22 

18 

17 

in  1851  and  1852,  with  2  and  1  deaths,  respectively,  and  in  1854  with  8  deaths. 
After  appearing  again  in  1859,  1868,  and  1870  with  1  death  in  each  year, 
this  disease  took  a  permanent  place  in  the  mortality  records  in  1873.  The  rates 
averaged  for  5-year  periods  are  given  in  table  118.  As  determined  by  recorded 
deaths,  the  force  of  mortality  of  diabetes  has  risen  by  very  gradual  steps  from 
an  insignificant  level  (rate  of  1)  in  1871-1875  to  one  of  considerable  impor¬ 
tance  (rate  of  20)  by  1916-1920.  By  1906-1910  its  mortality-rate  was  equal 
to  and  by  1916-1920  was  double  that  for  cirrhosis  of  the  liver.  While  some 
of  this  increase  of  importance  of  diabetes  as  a  cause  of  death  may  be  only  appar¬ 
ent,  and  explainable  by  better  medical  diagnosis  and  more  careful  classification, 
there  is  little  doubt  that  the  larger  part  is  real. 

The  influence  of  race  and  age  upon  the  mortality  from  diabetes  in  1920  is 
shown  in  table  119.  The  rate  was  29  per  cent  greater  in  whites  than  in 
31 


476  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

negroes.  For  the  whole  population,  the  rate,  which  was  only  1  in  the  first,  2 
in  the  second,  and  7  and  6  in  the  third  and  fourth  decades,  respectively, 
increased  markedly  in  each  succeeding  decade  until  the  eightieth  year  of  life, 
after  which  there  was  a  considerable  fall.  Among  whites  the  mortality  fol¬ 
lowed  the  same  general  course  with  the  highest  rates  in  the  eighth  decade. 
Among  negroes  there  were  no  deaths  earlier  than  the  thirtieth  year,  and  thn 
highest  rate  occurred  in  the  seventh  decade  of  life. 

ALCOHOLISM. 

In  the  statistical  records  deaths  have  been  attributed  to  alcoholism  in  each 
year  since  1818.  Deaths  from  this  cause  were  classified  under  intemperance 
from  1818  to  1898,  under  delirium  tremens  from  1844  to  1898,  and  under 
alcoholism,  acute  and  chronic  (rubric  56)  from  1899.  Annual  mortality-rates 
for  these  rubrics  separate  and  combined,  are  given  in  table  117.  It  will  be 
observed  that  for  this  cause  of  death  intemperance  was  the  sole  rubric  during 
the  period  of  highest  mortality  and  remained  by  far  the  most  important  rubric 
until  its  disappearance  in  1899,  and  that,  in  consequence,  during  the  55  years 
of  its  presence  in  the  statistical  tables,  to  delirium  tremens  was  ascribed  but 
a  small  proportion  of  the  total  mortality  from  alcoholism.  Deferring  for  the 
moment  consideration  of  all  questions  in  regard  to  their  accuracy  and  taking 
the  recorded  figures  at  their  face  value  in  measuring  the  mortality  from  alco¬ 
holism,  two  features  stand  out  prominently;  first,  the  wide  variations  between 
the  extremes  of  the  annual  rates,  from  83  in  1819  to  1  in  1867  and  in  1920, 
and  second,  the  occurrence  of  several  distinct  waves,  each  extending  over  a 
considerable  series  of  years  and,  with  one  exception,  of  progressively  decreas¬ 
ing  intensity.  The  first  and  highest  wave,  beginning  with  a  rate  of  26  in  1818 
and  reaching  its  peak  with  a  rate  of  83  in  1819,  declined  somewhat  irregularly 
to  the  comparatively  low  level  of  15  in  1828.  The  second  wave,  with  its  peak- 
rate  of  51  in  1831,  ended  in  1844  with  a  rate  of  8.  The  third  wave,  extending 
from  1845  to  1855,  reached  its  highest  point  in  1849  and  1852  with  a  rate  of 
24  and  fell  to  9  in  1855.  The  fourth  wave,  with  unusually  low  rates,  lasted 
from  1856  to  1867.  The  fifth  wave,  long  and  irregular,  reached  its  peak  in 
1875  with  a  rate  of  14  and  receded  to  its  low  point  with  a  rate  of  3  by  1897. 
In  the  last  wave,  which  attained  its  highest  level  with  a  rate  of  11  in  1905  and 
1906,  the  decline  was  gradual  though  irregular  until  1917,  after  which  the 
descent  was  abrupt  to  a  rate  of  1  in  1920. 

The  progressively  decreasing  intensity  of  these  waves  of  recorded  mortality 
from  alcoholism  is  well  illustrated  by  the  rates  as  averaged  for  5-year  periods 
(table  118).  From  an  average  height  of  over  50  up  to  1825,  by  1856-1860 
the  rate  had  fallen  to  14,  and  from  this  time  on  was,  with  the  exception  of  1 
quinquennial  period,  always  under  10.  Long  before  prohibition,  the  mortality 
officially  ascribed  to  alcoholism  had  become  almost  negligible.  Data  for  a  com¬ 
prehensive  study  of  the  relation  of  age,  sex,  and  race  to  the  mortality  from 
alcoholism  are  lacking. 

Unfortunately,  there  are  no  definite  criteria  for  judging  the  degree  of 
accuracy  with  which  the  recorded  data  represent  the  true  lethal  force  of  alco¬ 
holism.  It  is  reasonable  to  suppose  that,  on  account  of  the  opprobrium  attached 
to  certain  extreme  types  of  over-indulgence  in  alcohol,  for  decedents  of  a 


VARIOUS  CHRONIC  ORGANIC  DISEASES 


477 


certain  degree  of  social  prominence,  in  many  instances  some  other  cause  of 
death  was  reported,  while  for  the  relatively  obscure  the  bald  truth  was  stated. 
It  may  well  be  that  in  later  years  many  deaths,  which  in  earlier  times  and 
before  the  development  of  knowledge  of  pathological  anatomy  and  patho¬ 
genesis  would  have  been  credited  to  alcoholism,  were  classified  under  chronic 
affections  of  particular  organs,  such  as  the  heart,  arteries,  liver,  kidneys,  and 
nervous  system,  in  the  causation  of  which,  for  reasons  more  or  less  convinc¬ 
ing,  alcohol  has  been  assigned  a  prominent  part.  The  course  of  the  annual 
rates  during  the  last  60  years,  when  a  rate  of  10  has  rarely  been  exceeded, 
suggests  very  strongly  that  some  at  least  of  the  decrease  in  the  recorded  mor¬ 
tality  is  to  be  explained  by  changes  in  medical  and  statistical  nosology  result¬ 
ing  in  crediting  to  alcoholism  only  those  deaths  occurring  in  delirium  tremens 
or  other  pathological  states  indicative  of  acute  or  at  least  of  actively  progressive 
alcoholic  poisoning.  The  relatively  great  decline  in  the  rate,  after  1918,  which 
followed  so  abruptly  upon  the  administrative  interference  with  sale  of  alcohol 
supports  this  view,  for  had  it  at  this  time  been  the  custom  to  classify  under  this 
rubric  any  large  proportion  of  the  deaths  remotely  due  to  alcohol,  the  fall  in 
the  rate  could  hardly  have  been  so  abrupt.  On  the  other  hand,  it  is  well 
established  that  in  earlier  times  ardent  spirits  were  consumed  with  much 
greater  constancy  and  liberality  than  in  recent  years.  The  partiality  for  strong 
drink  of  men  connected  with  shipping  is  well-known,  and  the  rise  and  fall  in 
the  mortality-rates  from  alcoholism  in  the  period  under  review  corresponds 
very  closely  with  the  growth  and  decline  of  the  shipping  trade. 


N  *  ku.  y  -i  ***mM - 


PART  VII.— MISCELLANEOUS  CAUSES  OF  DEATH. 

Chapter  XVI. — Violence. 

(Tables  120  to  123,  graphs  30  to  32.) 

For  convenience,  under  this  heading  will  be  discussed  deaths  resulting 
directly  or  indirectly  from  man’s  acts.  These  may  be  divided  into  two  general 
classes,  accordingly  as  the  actions  are  intentional  or  unintentional.  Under 
the  former  class  fall  deaths  from  homicide  and  suicide,  and  to  the  latter  class 
belong  deaths  in  the  broad  sense  accidentally  caused  by  drowning,  poison, 
fire,  gases,  weapons,  falls,  injuries  by  machines,  vehicles,  animals,  and  elec¬ 
tricity.  In  either  case,  death  may  be  the  result  of  the  intentional  or  of  the 
unintentional  acts  of  the  victim  himself  or  of  other  persons.  It  is  to  be  recog¬ 
nized  that  to  a  very  considerable  degree  the  fatalities  under  both  these  cate¬ 
gories  are  dependent  upon  a  wide  variety  of  conditions  inherent  in  the  cir¬ 
cumstances  in  which  the  victims  are  situated  in  particular  periods  of  life  and 
of  the  city’s  history.  Among  the  most  important  of  these  are  age,  occupation, 
location,  and  the  character  and  degree  of  the  moral,  political,  mechanical, 
industrial,  and  financial  development.  There  can  be  little  doubt  that  race 
stock  has  exerted  a  determining  influence.  In  illustration,  a  few  pertinent 
examples  of  the  facts  upon  which  these  generalizations  are  based  may  be 
cited  here.  Homicides  have  been  unusually  frequent  in  times  of  political  con¬ 
tention,  and  suicides  have  often  increased  in  periods  of  financial  depression 
and  with  the  decrease  in  the  proportion  of  negroes  and  the  relative  increase 
of  certain  other  elements  in  the  population.  Drownings  have  become  rela¬ 
tively  fewer  with  the  decline  of  the  sailing  ship  and  of  the  indulgence  in 
aquatic  sports  with  the  gradual  removal  of  the  residential  section  from  prox¬ 
imity  to  the  water-front.  The  incidence  as  a  cause  of  accidental  death  of 
burns,  occurring  very  largely  in  young  children,  was  influenced  unfavorably 
by  the  use  of  open  fire-places  and  coal-oil  and  gas  stoves  and  favorably  by  the 
introduction  of  coal  furnaces.  Deaths  from  machinery  accidents  have  varied 
with  the  extension  of  the  use  of  machinery  and  perhaps  with  practical  legisla¬ 
tion.  Fatalities  from  vehicular  accidents  have  greatly  increased  with  the 
growth  of  railway  service,  the  introduction  of  electric  power  for  street  rail¬ 
ways,  and  particularly  of  late  years  with  the  development  of  the  automobile. 
Since  a  large  proportion  of  the  deaths  classified  under  accidental  falls  and 
fractures  occur  in  the  aged,  the  relative  number  of  deaths  attributable  to  these 
causes  is  directly  influenced  by  changes  in  the  ratio  of  those  of  advanced  age 
in  the  population. 

Mortality  data  for  this  group  as  a  whole  and  for  homicide,  suicide,  drown¬ 
ing,  and  other  accidents  for  the  years  1812  to  1920,  inclusive,  are  given  in 
table  120,  graph  30.  It  will  be  noted  that  deaths  ascribed  to  starvation,  to 
excess  of  heat  and  cold,  and  to  lightning  are  not  included.  Though  the  rates 
often  fluctuate  considerably,  not  only  from  year  to  year,  but  from  one  period  to 
another,  this  group  as  a  whole  has  been  continuously  a  major  cause  of  death. 

479 


480  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


Table  120. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  by 
violence,  and  the  percentage  of  deaths  by  violence  of  total  deaths  from  1812  to 
1920,  inclusive. 

D  =  death.  R  =  rate. 


Year. 

Homicides  and  suicides- 

Accidents. 

Total. 

Percentage 
to  total 
deaths. 

Homi¬ 

cides. 

l 

Suicides. 

Total. 

Drown. 

ings. 

Other  ac¬ 
cidents. 

Total. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1812  . 

8 

20 

2 

5 

10 

24 

28 

68 

19 

46 

47 

115 

57 

139 

5 

1813  . 

1 

2 

1 

2 

2 

5 

27 

63 

31 

72 

58 

136 

60 

140 

5 

1814  . 

2 

4 

1 

2 

3 

7 

12 

27 

15 

34 

27 

60 

30 

67 

3 

1815  . 

2 

4 

4 

9 

6 

13 

23 

49 

22 

47 

45 

96 

51 

109 

4 

1816  . 

2 

4 

1 

2 

3 

6 

20 

41 

27 

55 

47 

96 

50 

102 

4 

1817  . 

3 

6 

5 

10 

8 

16 

38 

75 

36 

71 

74 

145 

82 

161 

6 

1818  . 

3 

6 

9 

17 

12 

23 

27 

51 

26 

49 

53 

100 

65 

122 

4 

1819  . 

7 

13 

3 

5 

10 

18 

31 

56 

19 

34 

50 

90 

60 

108 

3 

1820  . 

4 

7 

4 

7 

8 

14 

20 

35 

17 

29 

37 

64 

45 

78 

3 

1821  . 

6 

10 

2 

3 

8 

13 

30 

50 

33 

55 

63 

104 

71 

118 

4 

1822  . 

5 

8 

3 

5 

8 

13 

16 

25 

52 

83 

68 

108 

76 

121 

3 

1823  . 

5 

8 

5 

8 

10 

15 

41 

63 

29 

44 

70 

107 

80 

122 

4 

1824  . 

3 

4 

5 

7 

8 

12 

27 

40 

24 

35 

51 

75 

59 

87 

4 

1825  . 

4 

6 

7 

10 

11 

16 

26 

37 

14 

20 

40 

56 

51 

72 

4 

1826  . 

5 

7 

4 

5 

9 

12 

29 

39 

44 

60 

73 

99 

82 

111 

4 

1827  . 

8 

10 

4 

5 

12 

16 

26 

34 

29 

38 

55 

72 

67 

87 

5 

1828  . 

1 

1 

5 

6 

6 

8 

27 

34 

35 

44 

62 

78 

68 

86 

4 

1829  . 

2 

2 

9 

11 

11 

13 

38 

46 

41 

50 

79 

96 

90 

109 

5 

1830  . 

3 

4 

5 

6 

8 

9 

44 

51 

33 

39 

77 

90 

85 

99 

4 

1831  . 

•  •  • 

%  •  • 

6 

7 

6 

7 

29 

33 

44 

50 

73 

82 

79 

89 

4 

1832  . 

5 

5 

5 

5 

10 

11 

23 

25 

36 

39 

59 

64 

69 

75 

2 

1833  . 

8 

8 

7 

7 

15 

16 

28 

29 

40 

42 

68 

71 

83 

87 

4 

1834  . 

5 

5 

4 

4 

9 

9 

31 

31 

45 

46 

76 

77 

85 

86 

3 

1835  . 

4 

4 

4 

4 

8 

8 

29 

28 

40 

39 

69 

67 

77 

75 

4 

1836  . 

3 

3 

10 

9 

13 

12 

25 

24 

47 

44 

72 

68 

85 

80 

4 

1837  . 

11 

10 

5 

5 

16 

15 

39 

36 

41 

37 

80 

73 

96 

88 

4 

1838  . 

5 

4 

6 

5 

11 

10 

23 

20 

51 

45 

74 

65 

85 

75 

3 

1839  . 

2 

2 

3 

3 

5 

4 

35 

30 

38 

32 

73 

62 

78 

67 

3 

1840  . 

4 

3 

7 

6 

11 

9 

22 

18 

38 

31 

60 

50 

71 

59 

3 

1841  . 

5 

4 

3 

2 

8 

6 

64 

51 

38 

30 

102 

82 

110 

88 

5 

1842  . 

3 

2 

5 

4 

8 

6 

47 

36 

62 

48 

109 

85 

117 

91 

5 

1843  . 

7 

5 

1 

1 

8 

6 

24 

18 

35 

26 

59 

44 

67 

50 

3 

1844  . 

11 

8 

5 

4 

16 

12 

27 

20 

37 

27 

64 

47 

80 

58 

3 

1845  . 

6 

4 

6 

4 

12 

8 

34 

24 

53 

37 

87 

61 

99 

70 

3 

1846  . 

13 

9 

4 

3 

17 

12 

40 

27 

50 

34 

90 

62 

107 

73 

4 

1847  . 

8 

5 

3 

2 

11 

7 

34 

23 

48 

32 

82 

55 

93 

62 

3 

1848  . 

6 

4 

5 

3 

11 

7 

31 

20 

57 

37 

88 

57 

99 

64 

3 

1849  . 

5 

3 

4 

3 

9 

6 

25 

16 

52 

33 

77 

48 

86 

54 

2 

1850  . 

8 

5 

5 

3 

13 

8 

29 

18 

50 

31 

79 

48 

92 

56 

2 

1851  . 

7 

4 

6 

4 

13 

8 

46 

27 

64 

38 

110 

65 

123 

73 

3 

1852  . 

16 

9 

11 

6 

27 

16 

42 

24 

75 

43 

117 

67 

144 

83 

3 

1853  . 

4 

2 

1 

1 

5 

3 

52 

29 

110 

62 

162 

91 

167 

94 

3 

1854  . 

12 

7 

10 

5 

22 

12 

47 

26 

133 

73 

180 

98 

202 

110 

4 

1855  . 

14 

7 

13 

7 

27 

14 

50 

27 

90 

48 

140 

74 

167 

89 

3 

1856  . 

51 

26 

8 

4 

59 

31 

43 

22 

98 

51 

141 

73 

200 

103 

4 

1857  . 

33 

17 

4 

2 

37 

19 

40 

20 

92 

46 

132 

66 

169 

85 

3 

1858  . 

24 

12 

3 

1 

27 

13 

42 

21 

63 

31 

105 

52 

132 

65 

2 

1859  . 

18 

9 

9 

4 

27 

13 

35 

17 

76 

36 

111 

53 

138 

66 

3 

1860  . 

9 

4 

12 

6 

21 

10 

41 

19 

91 

42 

132 

62 

153 

71 

3 

1861  . 

15 

7 

10 

5 

25 

11 

33 

15 

96 

44 

129 

59 

154 

70 

3 

1862  . 

28 

12 

1 

«  •  « 

29 

13 

50 

22 

91 

40 

141 

63 

170 

75 

3 

1863  . 

19 

8 

6 

3 

25 

11 

55 

24 

99 

43 

154 

67 

179 

77 

3 

1864  . 

21 

9 

2 

1 

23 

10 

47 

20 

100 

42 

147 

62 

170 

72 

3 

1865  . 

9 

4 

5 

2 

14 

6 

52 

21 

83 

34 

135 

56 

149 

61 

3 

1866  . 

19 

8 

7 

3 

26 

10 

49 

20 

82 

33 

131 

53 

157 

63 

3 

MISCELLANEOUS  CAUSES  OF  DEATH 


481 


Table  120. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  by 

violence,  etc. — Continued. 


Year. 


1867  . 

1868  . 

1869  . 

1870  . 

1871  . 

1872  . 

1873  . 

1874  . 

1875  . 

1876  . 

1877  . 

1878  . 

1879  . 

1880  . 

1881  . 

1882  . 

1883  . 

1884  . 

1885  . 

1886  . 

1887  . 

1888  . 

1889  . 

1890  . 

1891  . 

1892  . 

1893  . 

1894  . 

1895  . 

1896  . 

1897  . 

1898  . 

1899  . 

1900  . 

1901  . 

1902  . 

1903  . 

1904  . 

1905  . 

1906  . 

1907  . 

1908  . 

1909  . 

1910  . 

1911  . 

1912  . 

1913  . 

1914  . 

1915  . 

1916  . 

1917  . 

1918  . 

1919  . 

1920  . 


D  =  death.  R  =  rate. 


Homicides  and  suicides. 

Accidents. 

Total. 

Percentage 
to  total 
deaths. 

Homi¬ 

cides. 

Suicides. 

Total. 

Drown- 

ings. 

Other  ac¬ 
cidents- 

Total. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

7 

3 

9 

4 

16 

6 

43 

17 

69 

27 

112 

44 

128 

50 

2 

9 

3 

9 

3 

18 

7 

52 

20 

106 

41 

158 

61 

176 

68 

3 

4 

2 

9 

3 

13 

5 

42 

16 

81 

30 

123 

46 

136 

51 

2 

18 

7 

16 

6 

34 

12 

58 

21 

97 

36 

155 

57 

189 

69 

3 

13 

5 

6 

2 

19 

7 

40 

14 

97 

35 

137 

49 

156 

56 

2 

8 

3 

15 

5 

23 

8 

52 

18 

120 

42 

172 

60 

195 

68 

2 

9 

3 

22 

8 

31 

11 

59 

20 

131 

45 

190 

65 

221 

76 

3 

6 

2 

20 

7 

26 

9 

50 

17 

124 

42 

174 

58 

200 

67 

3 

8 

3 

20 

7 

28 

9 

42 

14 

115 

38 

157 

51 

185 

61 

3 

8 

3 

13 

4 

21 

7 

59 

19 

121 

39 

180 

58 

201 

65 

3 

27 

8 

18 

6 

45 

14 

44 

14 

90 

28 

134 

42 

179 

56 

2 

17 

5 

21 

6 

38 

12 

52 

16 

78 

24 

130 

40 

168 

52 

3 

35 

11 

15 

5 

50 

15 

51 

15 

78 

24 

129 

39 

179 

54 

2 

47 

14 

18 

5 

65 

19 

54 

16 

120 

35 

174 

51 

239 

71 

3 

65 

19 

23 

7 

88 

25 

39 

11 

84 

24 

123 

36 

211 

61 

2 

79 

22 

30 

9 

109 

31 

42 

12 

114 

32 

156 

44 

265 

75 

3 

20 

6 

26 

7 

46 

13 

55 

15 

135 

38 

190 

53 

236 

66 

3 

25 

7 

20 

5 

45 

12 

58 

16 

156 

43 

214 

58 

259 

71 

3 

15 

4 

28 

7 

43 

11 

42 

11 

169 

45 

211 

56 

254 

68 

3 

19 

5 

31 

8 

50 

13 

36 

9 

129 

34 

165 

43 

215 

56 

3 

15 

4 

43 

11 

58 

15 

50 

13 

152 

39 

202 

52 

260 

67 

3 

15 

4 

35 

8 

50 

12 

45 

11 

172 

41 

217 

52 

267 

64 

3 

30 

7 

32 

7 

62 

15 

62 

15 

160 

37 

222 

52 

284 

67 

3 

27 

6 

25 

6 

52 

12 

73 

17 

166 

38 

239 

55 

291 

67 

3 

10 

2 

39 

9 

49 

11 

51 

12 

222 

50 

273 

62 

322 

73 

3 

21 

5 

48 

11 

69 

15 

61 

14 

239 

53 

300 

67 

369 

82 

3 

22 

5 

50 

11 

72 

16 

57 

12 

262 

57 

319 

79 

391 

86 

4 

18 

4 

48 

10 

66 

14 

66 

14 

207 

45 

273 

59 

339 

73 

4 

26 

6 

43 

9 

69 

15 

44 

9 

324 

69 

368 

78 

437 

93 

4 

20 

4 

48 

10 

68 

14 

60 

13 

261 

55 

321 

67 

389 

81 

4 

21 

4 

60 

12 

81 

17 

56 

12 

231 

48 

287 

59 

368 

76 

4 

32 

6 

56 

11 

88 

18 

31 

6 

226 

46 

257 

52 

345 

70 

3 

13 

3 

54 

11 

67 

13 

63 

13 

265 

53 

328 

66 

395 

79 

4 

27 

5 

72 

14 

99 

20 

57 

11 

311 

61 

368 

73 

467 

92 

4 

22 

4 

61 

12 

83 

16 

56 

11 

275 

54 

331 

64 

414 

81 

4 

16 

3 

60 

12 

76 

15 

56 

11 

326 

63 

382 

73 

458 

88 

4 

14 

3 

58 

11 

72 

14 

44 

8 

324 

61 

368 

70 

440 

83 

4 

24 

4 

81 

15 

105 

20 

47 

9 

313 

59 

362 

68 

467 

87 

4 

19 

4 

88 

16 

107 

20 

47 

9 

371 

69 

418 

77 

525 

97 

5 

26 

5 

70 

13 

96 

18 

61 

11 

372 

68 

433 

79 

529 

97 

5 

41 

7 

83 

15 

124 

22 

54 

10 

396 

72 

450 

81 

574 

104 

5 

19 

3 

98 

18 

117 

21 

55 

10 

319 

57 

374 

67 

491 

88 

5 

18 

3 

101 

18 

119 

21 

47 

8 

335 

59 

382 

67 

501 

88 

5 

14 

2 

77 

13 

91 

16 

49 

9 

358 

63 

407 

71 

498 

87 

5 

27 

5 

100 

17 

127 

22 

45 

8 

302 

52 

347 

60 

474 

82 

5 

22 

4 

88 

15 

110 

19 

52 

9 

313 

54 

365 

62 

475 

81 

5 

41 

7 

118 

20 

159 

27 

58 

10 

349 

59 

407 

69 

566 

96 

6 

44 

7 

138 

23 

182 

31 

46 

8 

373 

63 

419 

70 

601 

101 

6 

48 

8 

101 

17 

149 

25 

58 

10 

360 

60 

418 

70 

567 

94 

6 

53 

9 

94 

15 

147 

24 

59 

10 

352 

58 

411 

68 

558 

92 

5 

52 

8 

100 

16 

152 

25 

64 

10 

560 

91 

624 

102 

776 

127 

7 

65 

11 

101 

16 

166 

27 

60 

10 

575 

93 

635 

103 

801 

130 

5 

57 

8 

98 

14 

155 

21 

64 

9 

544 

75 

608 

84 

763 

106 

7 

52 

7 

88 

12 

140 

19 

37 

5 

465 

63 

502 

68 

642 

87 

6 

482  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


The  total  rate  declined  from  139  in  1812  to  50  in  1843.  Gradually  rising 
again  to  110  by  1854,  it  slowly  receded  to  50  in  1867.  From  this  date,  though 
with  wavering  steps,  the  rate  gradually  rose  to  130  in  1918.  By  1920  it  had 
fallen  to  87. 

For  homicide,  the  annual  rates  have  varied  within  wide  limits,  the  extremes 
being  zero  in  1831  and  26  in  1856.  While  relatively  high  and  low  annual  rates 
often  alternated,  a  decided  tendency  to  epidemic  waves  covering  periods  of 
years  is  evident.  Conspicuous  in  this  regard  are  the  periods  1818-1821,  1854- 
1859,  1879-1882,  1913-1920.  The  high  rates  (20)  attained  in  1812  and  in 
certain  years  of  the  fifth,  sixth,  and  ninth  decades  of  the  nineteenth  century 
occurred  in  times  of  intense  political  rivalry,  which  were  often  characterized 
by  feuds  and  riots. 


Graph  30  (from  table  120).  Annual  crude  mortality -rates  from  different 
types  of  violence,  from  1812  to  1920,  inclusive- 


For  suicides,  the  fluctuation  in  the  rates  from  year  to  year,  especially  in 
the  period  prior  to  1880,  was  even  more  marked  than  for  homicide.  The 
extremes  were  rates  of  1  in  1843,  1853,  1858,  and  1864,  and  of  17  in  1818  for 
the  early  years,  and  of  23  in  1914  for  the  later  years.  It  will  be  noted  that 
the  rates,  which  were  low  in  1812  to  1814,  rose  after  the  close  of  the  war  in 
1815  and  maintained  a  comparatively  high  level  for  over  15  years.  After 
this  period  the  course  of  the  rates  was  very  irregular,  but,  on  the  whole,  rela¬ 
tively  low  until  after  1870.  During  the  Civil  War  the  rates  were  conspicuously 
low.  After  1880  the  rates  gradually  rose  and  the  annual  fluctuations  became 
much  less  marked.  From  the  peak-rate  of  23  attained  in  1914,  the  rate  receded 
during  the  period  of  the  World  War  and  by  1920  had  fallen  50  per  cent  to  12, 
the  lowest  rate  since  1903.  From  a  special  table  in  the  annual  report  for  1892, 


MISCELLANEOUS  CAUSES  OF  DEATH 


483 


giving  the  annual  number  of  deaths  from  suicide  from  1875  to  1892,  inclusive, 
it  appears  that  the  total  of  489  suicides  were  distributed  by  sex  and  color  as 
follows:  White  males,  394;  white  females,  87;  colored  males,  5;  and  colored 
females,  3.  Accidental  drowning,  until  1830  a  serious  rival  of  all  other  acci¬ 
dents  as  a  cause  of  death,  gradually  declined  from  peak-rate  of  75  in  1817  to 
the  relatively  inconsiderable  rate  of  5  in  1920.  While  the  course  of  the  rates 
was  subject  to  fluctuations  from  year  to  year  and  over  longer  periods,  it  is,  on 
the  whole,  comparatively  regular. 

The  rates  for  deaths  from  all  other  accidents  have  varied  within  wide  limits, 
from  20  in  1825  to  93  in  1918.  Though  subject  to  marked  variations  in  level, 
in  general  the  course  of  the  rates  between  1812  and  1843  was  downward.  A 
succession  of  three  rather  smoothly  outlined  waves  occurred  between  1844  and 
1878.  The  course  of  the  rates  since  1881  is  marked  by  a  long  upward  sweep, 
broken  here  and  there  by  crests  and  depressions,  to  93  in  1918,  and  with  a 


Table  121. — Absolute  figures  of  deaths  by  accident,  except  drowning,  for  the  years  1900, 

1905,  1910,  1915,  and  1920. 


Causes  of  death. 

1900 

1905 

1910 

1915 

1920 

Poisoning  by  food.  (164) . 

1 

4 

8 

Other  acute  poisonings.  (165) . 

9 

20 

8 

6 

9 

Conflagration.  (166)  . 

13 

77 

6 

5 

9 

Burns.  (167)  . 

80 

70 

81 

Deleterious  gases.  (168) . 

16 

14 

16 

10 

28 

Traumatism  by  firearms.  (170) . 

9 

9 

7 

2 

6 

Traumatism  by  cutting  and  piercing  instruments.  (171)  .... 

•  •  •  • 

•  •  •  • 

1 

1 

1 

Traumatism  by  fall.  (172) . 

7 

37 

80 

81 

109 

Traumatism  in  mines  and  quarries.  (173) . 

1 

1 

Traumatism  by  machines.  (174) . 

15 

5 

22 

Traumatism  by  crushing.  (Vehicles,  etc.)  (175) . 

72 

88 

93 

76 

161 

Traumatism  by  animals.  (176) . 

2 

2 

2 

Traumatism  by  electricity.  (Lightning  excepted.) . 

3 

6 

9 

•  •  •  • 

8 

Fractures.  (Cause  not  specified.)  (185) . 

73 

63 

7 

2 

•  •  •  • 

Other  external  violence.  (186) . 

59 

57 

30 

12 

20 

Total  . 

254 

314 

366 

276 

465 

recession  to  63  in  1920.  The  unusually  high  rates  for  1917  and  1918  were 
associated  with  a  considerable  increase  of  accidents  in  connection  with  the 
feverish  war  activities.  For  example,  in  1918,  the  number  of  deaths  from 
machinery,  falls,  vehicles,  and  “  other  external  violence  ”  exceeded  that  for 
1920  by  110,  or  24  per  cent. 

From  table  121,  in  which  are  given  the  absolute  figures  for  the  main  cate¬ 
gories  of  accidents  except  drowning  for  the  years  1900,  1905,  1910,  1915,  and 
1920,  a  very  good  idea  is  gained  of  the  relative  lethal  importance  of  the 
various  types  of  accidents.  Owing  to  modifications  in  the  official  classification, 
the  rubrics  poisoning,  burns,  falls,  and  other  external  violence  in  1900  and 
1905  are  not  strictly  comparable  with  those  in  the  later  years.  The  predomi¬ 
nant  importance  of  deaths  due  to  burns,  falls  (with  fractures  due  to  falls), 
and  vehicles  is  clear.  The  increase  in  the  number  of  deaths  under  the  latter 
rubric  was  due  to  automobiles.  The  small  part  played  by  machinery  indicates 
that  the  death-toll  paid  directly  to  manufacturing  is  relatively  light. 


484  PUBLIC  HEALTH  ADMINISTKATION,  ETC.,  IN'  BALTIMOBE 

The  influence  of  age  and  color  upon  accidental  death  in  an  average  year  is 
illustrated  in  table  122.  The  high  proportion  of  negroes  and  of  non-residents 
is  striking.  The  large  proportion  of  the  deaths  attributed  to  falls  in  individ¬ 
uals  over  the  sixty-fifth  year  indicates  the  conspicuous  part  played  by  falls 
resulting  in  fractures  followed  by  death  in  the  aged.  Nearly  half  the  vehicular 
deaths  were  caused  by  injuries  from  automobiles  and  a  strikingly  large  share  of 
all  deaths  from  vehicular  accidents  occurred  in  non-residents,  most  of  whom 
were  brought  to  the  city  for  surgical  care  after  injury. 

From  the  rates  averaged  for  5-year  periods  (table  123,  graph  31),  it  is  evi¬ 
dent  that  the  chance  of  a  violent  end  of  life  in  1915-1920  was  nearly  as  good 
as  it  was  in  1812-1815.  Drowning  is  the  only  one  of  this  group  of  causes  of 
death  that  has  shown  any  decrease  in  rate.  Homicide  holds  its  own,  and 


Table  122. — Influence  oj  age  and  color  upon  the  absolute  number  of  deaths  by  accident 

for  1917. 


Poisoning. 

Burns,  conflagrat  ions. 

Burns  and  scalds- 

Asphyxia,  acid. 

Gas  from  oil  stove. 

Illuminating  gas. 

Suffocation  in  bed. 

Drowning. 

Firearms. 

Cutting  instruments. 

Falls. 

Machinery. 

Elevators. 

Automobiles- 

Street  cars. 

Steam  railroads. 

Other  vehicles. 

Landslides. 

Total  . 

16 

13 

78 

1 

4 

18 

5 

64 

9 

1 

115 

13 

7 

76 

47 

27 

15 

2 

White  . 

11 

11 

50 

•  • 

4 

18 

3 

42 

8 

1 

102 

8 

2 

68 

34 

20 

13 

1 

Colored  . 

5 

2 

28 

1 

#  # 

2 

22 

1 

13 

5 

5 

8 

13 

7 

2 

1 

Non-residents  . 

•  • 

4 

11 

8 

6 

17 

3 

7 

21 

10 

9 

4 

Under  1  year . 

•  • 

2 

3 

5 

Between  1  and  2  yrs. 

1 

1 

6 

•  • 

1 

2 

•  • 

•  • 

1 

2  to  4  years . 

3 

•  • 

23 

•  • 

2 

6 

•  • 

•  • 

8 

3 

5  to  14  years . 

1 

•  • 

16 

12 

1 

5 

•  • 

1 

26 

7 

1 

3 

15  to  24  years . 

1 

1 

5 

8 

4 

6 

4 

2 

9 

7 

3 

•  • 

25  to  44  years . 

5 

5 

8 

#  , 

1 

4 

28 

4 

18 

2 

3 

14 

13 

13 

8 

1 

45  to  65  years . 

5 

1 

12 

1 

•  • 

10 

14 

•  • 

31 

7 

1 

13 

14 

10 

3 

1 

66  years  and  over . . . 

•  • 

3 

5 

•  • 

•  • 

4 

2 

•  • 

1 

47 

•  • 

•  • 

5 

3 

•  • 

1 

•  • 

suicides  and  accidents  other  than  drowning  have  actually  increased.  The  rate 
for  suicide  has  indeed  multiplied  three  times.  The  course  of  the  curves  for 
homicide  and  suicide  suggests  the  possibility  that  to  some  degree  the  ultimate 
motives  underlying  these  acts  are  interrelated.  It  will  be  noted  that  when  the 
rates  for  one  are  high,  those  for  the  other  are  commonly  low.  The  curve  of 
the  rates  for  deaths  from  intentional  violence — homicides  and  suicides  taken 
together — shows  a  very  distinct  rise  over  the  109  years  under  review,  and  is 
marked  by  four  definite  peaks,  of  which  each  of  the  last  three  is  higher  than 
its  predecessor.  These  peaks  fall  in  the  5-year  periods  1815-1820,  1856-1860, 
1881-1885,  and  1911-1915,  and  are  therefore  separated  by  periods  of  about 
30  years.  The  curve  for  the  rates  for  unintentional  violence — all  accidental 
deaths — falls  rather  regularly  on  the  whole  between  1812-1815  and  1876- 
1880,  and  then  ascending  steadily  throughout  the  rest  of  its  course,  and  in 
spite  of  the  constantly  decreasing  importance  of  drowning,  ends  at  a  level  of 
only  20  per  cent  less  than  at  the  beginning.  As  judged  by  rates  averaged 


MISCELLANEOUS  CAUSES  OF  DEATH 


485 


Table  123. — Average  rate  oj  death,  per  100,000  living  inhabitants,  by  5-  and  10-year 

periods  from  violence,  from  1812  to  1920,  inclusive. 


Periods. 

Homicides  and  suicides. 

Accidents- 

Total. 

Homi¬ 

cides- 

Suicides- 

Total. 

Drown- 

ings. 

Other  ac¬ 
cidents. 

Total. 

By  5-year 
periods- 

BylO-year 

periods. 

By  5-year 

periods- 

BylO-year 

periods- 

By  5-year 

periods. 

BylO-year 

periods- 

By  5-year 

periods. 

BylO-year 

periods. 

By  5-year 

periods. 

BylO-year 

periods. 

By  5-year 

periods. 

BylO-year 

periods. 

By  5-year 

periods. 

BylO-year 

periods. 

1812-15  . 

8 

•  •  • 

5 

12 

•  •  • 

52 

•  •  • 

50 

•  •  • 

102 

•  •  • 

114 

•  •  • 

1816-20  . 

7 

7 

8 

7 

15 

14 

51 

50 

48 

49 

99 

100 

114 

114 

1821-25  . 

7 

•  •  • 

7 

•  •  • 

14 

•  •  • 

43 

... 

47 

•  •  • 

90 

... 

104 

... 

1826-30  . 

5 

6 

7 

7 

12 

13 

41 

42 

46 

47 

87 

89 

99 

101 

1831-35  . 

5 

•  •  • 

5 

•  •  • 

10 

•  •  • 

29 

•  •  • 

43 

•  •  • 

72 

•  •  • 

82 

•  •  • 

1836-40  . 

4 

5 

6 

6 

10 

10 

26 

27 

38 

41 

64 

68 

74 

78 

1841-45  . 

5 

•  •  • 

3 

•  •  • 

8 

•  •  • 

30 

•  •  • 

34 

•  •  • 

64 

•  •  • 

71 

•  •  • 

1846-50  . 

5 

5 

3 

3 

8 

8 

21 

25 

33 

34 

54 

59 

62 

67 

1851-55  . 

6 

•  •  • 

5 

•  •  • 

10 

•  •  • 

27 

•  •  • 

53 

•  •  • 

79 

•  •  • 

90 

... 

1856-60  . 

14 

10 

4 

4 

17 

14 

20 

23 

41 

47 

61 

70 

78 

84 

1861-65  . 

8 

•  •  • 

2 

•  •  • 

10 

•  •  • 

20 

... 

41 

•  •  • 

61 

•  •  • 

71 

•  •  • 

1866-70  . 

4 

6 

4 

3 

8 

9 

19 

20 

33 

37 

52 

57 

60 

66 

1871-75  . 

3 

•  •  • 

6 

•  •  • 

9 

•  •  • 

17 

•  •  • 

40 

•  •  • 

57 

•  •  • 

66 

•  •  • 

1876-80  . 

8 

6 

5 

5 

13 

11 

16 

16 

30 

35 

46 

51 

59 

63 

1881-85  . 

12 

•  •  • 

7 

•  •  • 

19 

•  •  • 

13 

•  •  • 

36 

•  •  • 

49 

•  •  • 

68 

1886-90  . 

5 

8 

8 

8 

13 

16 

13 

13 

38 

37 

51 

50 

64 

66 

1891-95  . 

4 

•  •  • 

10 

•  •  • 

14 

... 

12 

•  •  • 

55 

... 

67 

•  •  • 

81 

•  •  • 

1896-1900  . 

5 

4 

12 

11 

16 

15 

11 

12 

52 

54 

63 

65 

80 

80 

1901-05  . 

4 

•  •  • 

13 

•  •  • 

17 

... 

10 

•  •  • 

61 

•  •  • 

71 

•  •  • 

87 

•  •  • 

1906-10  . 

4 

4 

15 

14 

20 

18 

10 

10 

64 

62 

73 

72 

93 

90 

1911-15  . 

6 

•  •  • 

18 

•  •  • 

25 

•  •  • 

9 

•  •  • 

57 

•  •  • 

66 

91 

•  •  • 

1916-20  . 

8 

7 

15 

17 

23 

24 

9 

9 

76 

67 

85 

76 

108 

100 

Graph  31  (from  table  123).  Crude  mortality-rates  from  different  types  of 
violence,  averaged  by  5-year  periods,  from  1812  to  1920,  inclusive. 


486  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


for  5-year  periods,  between  1812  and  1920,  the  mortality  for  intentional 
violence  increased  by  100  per  cent,  the  mortality  for  unintentional  violence 
decreased  by  20  per  cent,  and  for  all  forms  of  violence  there  was  a  decrease 
in  mortality  of  only  5.5  per  cent. 


1,000 


' -  GRAND  TOTAL 

— - SUICIDES 

- HOMICIDES 

- TOTAL  -  SUICIDES  AND  HOMICIDES 

- DR  OWNINGS 

- OTHER  ACCIDENTS 

. —  TOTAL  DPOWN/UOS  AND  OTHER  ACCIDENTS 


8  loo 


/  U - 1 - 1 - 1 - 1 - 1 - 1 - 1 - 1 - 1 - ! - 

Id  IE  20  JO  AO  SO  60  70  DO  SO  1900  10  20 

YEAR 


Graph  32  (from  table  123).  Crude  mortality-rates  from  different  types  of 
violence,  averaged  by  10-year  periods,  from  1812  to  1920,  inclusive. 


Chapter  XVII. — Child-Birth. 

(Tables  124  to  127,  graphs  33  to  34.) 

Deaths  from  this  group  of  causes  were  recorded  under  the  single  rubric, 
“  childbed,”  until  1875,  when  those  from  puerperal  fever  were  classified 
under  a  new  rubric  of  that  title.  Since  the  adoption  of  the  international 
classification  in  1899,  deaths  of  women  from  causes  connected  with  child¬ 
birth  have  been  classified  under  the  eight  rubrics,  134  to  141,  of  this  statisti¬ 
cal  nosology.  From  the  relatively  small  number  of  deaths  ascribed  to  child¬ 
bed  in  the  earlier  years,  it  is  perhaps  fair  to  assume  that  the  assignments  of 
deaths  under  this  rubric  was  specific,  that  is,  restricted  to  deaths  of  mothers 
due  to  causes  connected  with  giving  birth  to  children,  and  did  not  include 
deaths  of  lying-in  women  from  general  causes.  Indeed,  it  is  not  unlikely  that 
the  term  was  used  in  a  narrower  sense  than  is  now  the  custom,  to  embrace  only 
deaths  of  women  from  causes  immediately  connected  with  giving  birth  to 
children,  living  or  still,  of  viable  age. 

In  the  discussion  of  natality  it  has  been  made  clear  that  before  1915  births 
were  not  reported  with  sufficient  accuracy  for  the  calculation  on  this  basis  of 
reliable  rates  of  maternal  risks  in  child-bearing.  Nor,  owing  to  the  uncer¬ 
tainties  connected  with  estimating  in  this  heterogeneous  population  from  year 
to  year  over  so  long  a  period,  the  number  of  women  of  the  usual  child-bearing 
age  (15  to  50  years),  is  it  practicable  to  calculate  rates  on  the  basis  next  in 
order  of  specificity.  Consequently,  for  the  years  1812  to  1914,  inclusive, 
maternal  mortality  from  child-bearing  must  be  measured  either  in  terms  of 
the  female  or  of  the  whole  population.  Rates  calculated  on  these  bases  are 
given  in  table  124,  graph  33.  The  following  discussion  of  the  puerperal  mor¬ 
tality  will  be  confined  to  the  former.  It  will  be  observed  that  these  rates  often 
vary  not  only  from  year  to  year,  but  over  long  series  of  years.  Rates  over  100 
obtained  in  years  so  widely  separated  as  1816  and  1872.  Rates  over  80  pre¬ 
vailed  in  a  number  of  years.  As  the  other  extreme,  rates  under  35  occurred 
in  both  early  and  recent  years,  in  some  years  of  the  third,  fourth,  fifth, 
sixth,  seventh,  and  tenth  decades  of  the  nineteenth  century,  and  frequently 
after  1900.  Fluctuations  from  very  high  to  very  low  rates,  and  vice  versa,  did 
not  occur  during  short  periods  of  2  or  3  years,  but  the  transition  to  opposite 
levels  was  usually  gradual. 

Taking  as  a  convenient  basis  of  comparison  the  rates  averaged  for  5-year 
periods  (table  125,  graph  34),  several  distinct  waves  of  high  mortality  are 
evident.  After  remaining  on  a  level  of  about  70  from  1812  to  1825,  during 
the  next  5  years  the  averaged  rate  declined  to  40.  Following  a  slight  reaction 
to  51  between  1831  and  1835,  the  rate  declined  for  10  years  and  reached  the 
comparatively  low  level  of  37  during  the  5  years  ending  in  1845.  Rebounding 
to  69  during  the  next  quinquennium,  the  rate  attained  80  between  1851-1855. 
Another  abrupt  decline  brought  the  rate  to  43  in  the  period  ending  in  1865. 
This  wave  was  immediately  succeeded  by  a  second  of  very  similar  proportions, 
with  a  peak-rate  of  79  between  1871  and  1875  and  with  a  decline  to  37  in  the 
next  5-year  period.  The  fluctuations  were  comparatively  slight  between  1881 

487 


488  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


Table  124. — Number  of  deaths  and  rate  of  death ,  per  100,000  living  inhabitants  and 
100,000  living  female  inhabitants,  from  causes  connected  with  child-birth,  from  1812 
to  1920,  inclusive. 


Year. 

Child-bed. 

Puerperal  fever. 

Total. 

Deaths. 

Rate  per 

100,000  total 
population. 

Rate  per 

100,000  female 

population. 

Deaths- 

Rate  per 

100,000  total 

population. 

Rate  per 

100,000  female 

population. 

Deaths- 

Rate  per 

100,000  total 

population. 

Rate  per 

100,000  female 

population. 

1812  . 

10 

26 

49 

1813  . 

16 

37 

74 

1814  . 

15 

34 

66 

1815  . 

22 

47 

93 

1816  . 

26 

53 

104 

1817  . 

14 

27 

54 

1818  . 

19 

36 

70 

1819  . 

18 

32 

63 

1820  . 

20 

35 

67 

1821  . 

24 

40 

77 

1822  . 

22 

35 

68 

1823  . 

28 

43 

82 

1824  . 

(2) 

(3) 

18 

26 

51 

1825  . 

22 

31 

60 

1826  . 

20 

27 

52 

1827  . 

15 

20 

37 

1828  . 

19 

24 

46 

1829  . 

13 

16 

30 

1830  . 

16 

19 

36 

1831  . 

24 

27 

51 

1832  . 

33 

36 

68 

1833  . 

25 

26 

50 

1834  . 

24 

24 

46 

1835  . 

21 

21 

39 

1836  . 

18 

17 

32 

1837  . 

29 

26 

50 

1838  . 

28 

25 

47 

1839  . 

21 

18 

34 

1840  . 

20 

17 

31 

1841  . 

31 

25 

47 

1842  . 

14 

11 

21 

1843  . 

21 

16 

30 

1844  . 

29 

21 

40 

1845  . 

34 

24 

45 

1846  . 

36 

25 

47 

1847  . 

35 

23 

44 

1848  . 

62 

40 

76 

1849  . 

78 

49 

93 

1850  . 

75 

46 

87 

1851  . 

70 

42 

78 

1852  . 

83 

48 

91 

1853  . 

65 

36 

69 

1854  . 

71 

39 

73 

1855  . 

90 

48 

90 

1856  . 

72 

37 

70 

1857  . 

62 

31 

59 

1858  . 

63 

31 

59 

1859  . 

46 

22 

42 

1860  . 

64 

30 

56 

1861  . 

59 

27 

51 

1862  . 

43 

19 

36 

1863  . 

64 

28 

52 

1864  . 

46 

19 

37 

1865  . 

47 

19 

37 

1866  . 

43 

17 

33 

MISCELLANEOUS  CAUSES  OF  DEATH 


489 


Table  124. — Number  of  deaths  and  rate  of  death ,  per  100,000  living  inhabitants, 

etc. — Continued. 


Year. 

Child-bed. 

Puerperal  fever. 

Total. 

i  

Deaths. 

Rate  per 

100,000  total 
population. 

Rate  per 

100.000  female 

population. 

Deaths. 

Rate  per 

100,000  total 

population. 

Rate  per 

100,000  female 

population. 

Deaths- 

Rate  per 

100,000  total 

population. 

Rate  per 

100,000  female 

population. 

1867  . 

84 

33 

63 

1868  . 

94 

36 

68 

1869  . 

113 

42 

80 

1870  . 

129 

47 

90 

1871  . 

146 

52 

99 

1872  . 

166 

58 

111 

1873  . 

113 

39 

74 

1874  . 

113 

38 

72 

1875  . 

35 

8 

22 

25 

6 

16 

60 

14 

37 

1876  . 

35 

11 

21 

13 

4 

8 

48 

15 

29 

1877  . 

31 

10 

19 

28 

9 

17 

59 

19 

35 

1878  . 

32 

10 

19 

26 

8 

15 

58 

18 

34 

1879  . 

48 

14 

28 

19 

6 

11 

67 

20 

38 

1880  . 

43 

13 

24 

40 

12 

22 

83 

25 

47 

1881  . 

41 

12 

23 

25 

7 

14 

66 

19 

36 

1882  . 

49 

14 

26 

38 

11 

21 

87 

25 

47 

1883  . 

41 

11 

22 

41 

11 

22 

82 

23 

43 

1884  . 

52 

14 

27 

44 

12 

23 

96 

26 

50 

1885  . 

49 

13 

25 

48 

13 

24 

97 

26 

49 

1886  . 

56 

15 

28 

55 

14 

27 

111 

29 

55 

1887  . 

42 

11 

19 

53 

14 

24 

95 

24 

43 

1888  . 

45 

11 

20 

52 

12 

23 

97 

23 

44 

1889  . 

48 

11 

21 

39 

9 

17 

87 

20 

39 

1890  . 

62 

14 

27 

34 

8 

15 

96 

22 

42 

1891  . 

66 

15 

28 

52 

12 

22 

118 

27 

51 

1892  . 

60 

13 

25 

54 

12 

23 

114 

25 

48 

1893  . 

60 

13 

25 

78 

17 

32 

138 

30 

57 

1894  . 

52 

11 

21 

40 

9 

16 

92 

20 

38 

1895  . 

43 

9 

17 

66 

14 

27 

109 

23 

44 

1896  . 

63 

13 

25 

54 

11 

22 

117 

24 

47 

1897  . 

41 

8 

16 

34 

7 

13 

75 

15 

29 

1898  . 

43 

9 

17 

22 

4 

9 

65 

13 

25 

1899  . 

81 

16 

31 

27 

5 

10 

108 

22 

41 

1900  . 

95 

19 

36 

31 

6 

12 

126 

25 

48 

1901  . 

71 

14 

27 

55 

11 

21 

126 

25 

47 

1902  . 

55 

11 

20 

62 

12 

23 

117 

22 

43 

1903  . 

53 

10 

19 

58 

11 

21 

111 

21 

40 

1904  . 

47 

9 

17 

59 

11 

21 

106 

20 

38 

1905  . 

46 

9 

16 

56 

10 

20 

102 

19 

36 

1906  . 

59 

11 

21 

43 

8 

15 

102 

19 

36 

1907  . 

44 

8 

15 

43 

8 

15 

87 

16 

30 

1908  . 

47 

8 

16 

45 

8 

16 

92 

16 

32 

1909  . 

66 

12 

23 

37 

7 

13 

103 

18 

35 

1910  . 

59 

10 

20 

27 

5 

9 

86 

15 

29 

1911  . 

54 

9 

18 

33 

6 

11 

87 

15 

29 

1912  . 

62 

11 

21 

43 

7 

14 

105 

18 

35 

1913  . 

63 

11 

21 

49 

8 

16 

112 

19 

37 

1914  . 

49 

8 

16 

35 

6 

11 

84 

14 

27 

1915  . 

55 

9 

18 

25 

4 

8 

80 

13 

26 

1916  . 

69 

11 

22 

35 

6 

11 

104 

17 

33 

1917  . 

57 

9 

18 

34 

6 

11 

91 

15 

29 

1918  . 

88 

14 

28 

31 

5 

10 

119 

19 

38 

1919  . 

103 

14 

28 

40 

6 

11 

143 

20 

39 

1920  . 

93 

13 

25 

40 

5 

11 

133 

18 

36 

490  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


Graph  33  (from  table  124).  Mortality-rates,  per  100,000  living  female 
inhabitants,  from  causes  connected  with  child-birth,  from  1812  to  1920, 
inclusive. 


Table  125. — Average  rate  of  death,  per  100,000  living  inhabitants  and  per  100,000  living 
female  inhabitants,  by  5-year  periods,  from  causes  connected  with  child-birth, 
from  1812  to  1920,  inclusive. 


Periods. 

Child-bed. 

Puerperal  fever. 

Total. 

Total  • 
population. 

Female 

population. 

Total 

population. 

Female 

population. 

Total 

population. 

Female 

population. 

1812-15  . 

36 

70 

1816-20  . 

37 

72 

1821-25  . 

35 

67 

1826-30  . 

21 

40 

1831-35  . 

27 

51 

1836-40  . 

21 

39 

1841-45  . 

19 

37 

1846-50  . 

27 

69 

1851-55  . 

42 

80 

1856-60  . 

30 

57 

1861-65  . 

22 

43 

1866-70  . 

35 

67 

1871-75  . 

39 

79 

1876-80  . 

12 

22 

8 

15 

19 

37 

1881-85  . 

13 

25 

11 

21 

24 

45 

1886-90  . 

12 

23 

11 

21 

24 

45 

1891-95  . 

12 

23 

13 

24 

25 

48 

1896-1900  . 

13 

25 

7 

13 

20 

38 

1901-05  . 

10 

20 

11 

21 

21 

41 

1906-10  . 

10 

19 

7 

14 

17 

33 

1911-15  . 

10 

19 

6 

12 

16 

31 

1916-20  . 

12 

24 

5 

11 

18 

35 

MISCELLANEOUS  CAUSES  OF  DEATH 


491 


and  1905.  During  the  remainder  of  the  period  the  rate  was  33  from  1906 
to  1910,  31  from  1911  to  1915,  and  35  from  1916  to  1920.  The  two  high 
waves  which  occurred  between  1846  and  1880  culminated  with  a  rate  on  a 
level  with  that  which  obtained  in  1841-1845  and  which  was  not  bettered  in 
any  subsequent  period  until  1906-1910. 

Kates  for  puerperal  fever  and  for  all  other  causes  combined,  for  which  sep¬ 
arate  data  exist  since  1875  (tables  124  and  125,  graphs  33  and  34),  run 
quite  different  courses.  As  averaged  for  5-year  periods  the  rate  for  other 
causes  of  maternal  deaths  follows  a  fairly  even  course.  During  the  whole 
term  this  rate  varied  only  between  25  and  19  and  the  level  was  nearly  the 
same  in  the  first  and  the  last  5-year  periods.  In  strong  contrast  with  this  com- 


Graph  34  (from  table  125).  Mortality-rates,  per  100,000  living  female 
inhabitants,  from  causes  connected  with  child-birth,  averaged  by  5-year 
periods,  from  1812  to  1920,  inclusive. 

parative  stability,  the  rate  for  puerperal  fever  varied  from  15  in  1875-1880 
and  24  in  1891-1895  to  11  in  1916-1920. 

There  were  two  very  distinct  high  waves  of  mortality,  one  between  1876 
and  1895  and  the  other  between  1901  and  1905.  From  the  last  peak  which 
was  attained  in  the  period  1901-1905,  the  rate  declined  continuously,  and  in 
the  period  1916-1920  it  stood  at  its  lowest  recorded  level.  These  two  con¬ 
siderable  waves  of  high  mortality  from  puerperal  fever  correspond  with  similar 
though  relatively  slight  changes  in  the  total  rate.  In  so  far  as  may  be  judged 
from  rates  so  crude,  this  picture  suggests  that  puerperal  fever,  like  other 
infectious  diseases,  has  run  in  epidemic  course  and  that  this  affection  was  the 
chief  factor  in  the  earlier  high  waves  of  total  child-bed  mortality. 

It  has  been  recently  pointed  out  by  the  writer  (66)  that  annual  rates  calcu¬ 
lated  from  the  sum  of  the  recorded  living  and  still-births  and  the  number 
32 


492  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


of  deaths  of  women  classified  under  affections  of  the  puerperal  state  (rubrics 
134  to  141,  inclusive)  express  in  terms  more  nearly  specific  than  those  com¬ 
monly  relied  on  the  actual  risk  of  death  of  women  definitely  exposed  in 
child-bearing.  Expressed  in  formal  terms  the  true  maternal  risk-rate  in 
child-bearing  is  derived  from  the  formula 

DP 

n  j)  _  _ 

~  BL  +  B8 

where  DP  equals  the  number  of  maternal  deaths  due  to  causes  definitely  con¬ 
nected  with  the  puerperal  state  and  BL  and  BS  equal  the  number  of  live  and 
still-births,  respectively.  It  was  recognized  that,  while  far  more  accurate  than 
those  in  common  use,  owing  to  certain  defects  in  the  divisor  connected  with 
the  definition  of  still-births  and  in  the  dividend  resulting  from  errors  in  the 
nosological  classification  of  maternal  deaths,  even  this  method  cannot  be 
expected  in  actual  practice  to  measure  with  absolute  accuracy  the  risk  to 
mothers  in  child-bearing,  nor  to  yield  figures  which  for  different  places  are 
strictly  comparable. 

The  term  still-birth  is  variously  defined  in  different  countries  and  in  dif¬ 
ferent  localities  in  the  same  country,  from  early  embryos  to  full-term  chil¬ 
dren  born  alive,  but  not  surviving  the  third  day  of  extra-uterine  life.  The 
mean  between  those  extremes,  in  most  countries  at  least,  is  represented  by  a 
dead-born  fetus  of  that  age-period  of  utero-gestation  at  which,  if  liveborn, 
extra-uterine  existence  is  possible,  or,  in  other  words,  a  dead-born  fetus  past 
the  sixth  month  after  conception.  After  consideration  of  available  data,  the 
conclusion  was  reached  that  in  1918  for  the  United  States  birth  registration 
area  as  a  whole,  the  number  of  still-births  reported  represented  the  actual  num¬ 
ber  of  fetuses  of  5  months  and  over  of  utero-gestation  born  dead.  It  was  found 
that  for  this  year  in  the  United  States  registration  area  the  proportion  of 
instances  of  plural  to  single  births  was  approximately  1  per  cent.  As  the 
reporting  of  live  births  is  complete  nowhere  in  the  United  States,  it  was 
thought  inadvisable  in  general  studies  based  on  the  natality  figures  of  this 
country  to  apply  this  obvious  correction.  The  inclusion  of  still-births  in  the 
divisor  is  demanded  on  medical  as  well  as  on  statistical  grounds,  for  many  of  the 
factors  which  cause  the  death  of  the  unborn  child,  or  which  accompany  or  fol¬ 
low  birth  of  a  still-born  child,  actually  increase  the  maternal  risks. 

The  dividend,  which  embraces  the  deaths  classified  under  rubrics  134  to 
141,  inclusive,  is  open  to  certain  obvious,  but  usually  overlooked,  errors.  While 
these  rubrics  are  specific  in  the  sense  that  they  do  not  include  deaths  occurring 
in  pregnant  women  due  to  ordinary  causes,  such  as  communicable  diseases 
(puerperal  infection  excepted)  and  cardio-renal  disease,  for  instance,  some  of 
them  are  not  specific  for  the  present  purpose.  To  six  of  the  eight  rubrics,  acci¬ 
dents  of  pregnancy  (134),  puerperal  hemorrhage  (135),  accidents  of  labor 
(136),  puerperal  septicemia  (137),  puerperal  albuminuria  and  convulsions 
(138),  and  phlegmasia  and  alba  dolens  (139),  are  credited  some  deaths  of 
women  from  these  causes  occurring  in  all  stages  of  the  pregnant  and  puerperal 
states  from  conception  to  weeks  after  the  completion  of  labor.  Accidents  of 
pregnancy  include  maternal  deaths  due  to  accidental  abortions,  miscarriages, 
extra-uterine  pregnancy,  and  vomiting  of  pregnancy  occurring  in  the  early 
months  of  gestation.  Puerperal  hemorrhage,  toxemias,  and  convulsions,  puer- 


MISCELLANEOUS  CAUSES  OF  DEATH 


493 


peral  infection  (after  abortions  and  miscarriages),  deformities  of  mother  or 
child,  injuries  and  operations,  and  any  of  the  vascular  lesions  enumerated 
under  rubric  139,  may  be  fatal  before  the  end  of  the  fifth  month  of  pregnancy. 

All  except  two  and  all  the  important  rubrics  include  some  maternal  deaths 
occurring  at  any  time  during  the  pregnant  state,  and  therefore  represent  not 
with  strict  accuracy  but  only  approximately  the  number  of  deaths  from  these 
causes  of  women  5  months  pregnant  and  over.  These  rubrics  were  set  up  on 
the  principle  of  measuring  the  deaths  of  the  whole  pregnant  state.  On  the 
other  hand,  by  the  consensus  of  opinion,  child-birth,  or  labor,  has  been 
restricted  to  the  act  of  bringing  into  the  extra-uterine  world  fetuses  of  at 
least  5  months  of  utero-gestation.  Therefore,  to  obtain  maternal  risk-rates 
strictly  specific  for  the  act  of  child-birth,  where  the  divisor  consists  of  the  total 
number  of  living  and  still-born  children  above  this  arbitrarily  fixed  stage  of 
development,  the  dividend  should  include  only  those  maternal  deaths  which 
occur  in  connection  with  the  horning  of  children  after  the  completion  of  the 
fifth  month  of  pregnancy.  To  determine  the  risk  of  death  to  women  of  becom¬ 
ing  pregnant,  that  is,  from  conception  to  several  weeks  after  expulsion  of 
the  living  or  dead  impregnated  ovum  of  whatever  period  of  development,  is 
impossible.  The  number  of  deaths  under  these  eight  rubrics  under  discussion 
furnish  the  dividend,  but  there  are  lacking  the  correct  figures  for  the  divisor, 
which  embrace  not  only  the  births  of  fetuses  over  the  fifth  month  of  gesta- 
tation,  but  the  large  and  entirely  unknown  number  of  miscarriages  and  of 
recognized  and  unrecognized  abortions. 

It  is  evident,  then,  that  from  the  recorded  data  it  is  impossible  to  calculate 
with  absolute  accuracy  the  risk  to  women  of  either  pregnancy  or  of  child-birth. 
For  determining  the  risk  of  death  in  child-birth  there  are  in  both  divisor  and 
dividend  certain  relatively  minor  errors  for  which,  under  methods  by  wlich 
the  data  are  collected  and  recorded,  fitting  allowances  for  correction  can  not 
be  made.  It  is  clear,  however,  that  the  method  here  employed  must  measure 
much  more  accurately  than  any  of  those  in  general  use  the  risk  to  women  of 
dying  from  causes  connected  with  child-birth. 

For  the  6-year  period  1915  to  1920,  the  living  and  still-births  have  been 
reported  with  sufficient  accuracy  for  the  calculation  on  the  basis  above  out¬ 
lined  of  specific  maternal  risk-rates  of  deaths  connected  with  child-birth.  The 
data  are  presented  in  table  126.  Considering  first  the  total  population,  that  is, 
whites  and  negroes  together,  it  will  be  noticed  that  the  rate  for  all  causes  in 
the  puerperal  state  not  only  reached  the  very  high  average  level  of  646,  but 
actually  rose  during  the  period  under  consideration  from  542  in  1915  to  659  in 
1920,  with  even  higher  rates  in  1918  and  1919.  Puerperal  infection,  with  an 
average  rate  of  197,  was  responsible  for  30  per  cent  of  the  deaths  from  this 
group  of  causes.  Puerperal  albuminuria  and  convulsions  ranked  next  and  rose 
to  a  level  almost  as  high.  The  rates  for  accidents  of  pregnancy  varied  con¬ 
siderably  from  year  to  year,  and  with  an  average  rate  of  101  and  average  per¬ 
centage  of  the  whole  number  of  deaths  of  15.8,  stood  third  in  order  of  fatality. 
Puerperal  hemorrhage  and  accidents  of  labor,  which  also  showed  marked 
annual  fluctuations  with  averaged  rates  of  75  and  67,  respectively,  were  of 
about  equal  lethal  force.  No  deaths  were  ascribed  to  rubrics  140  and  141. 
The  fatality  of  the  puerperal  affections  in  whites  and  in  negroes  may  be  com¬ 
pared  for  1919  and  1920.  Taking  the  average  for  the  two  years  it  is  to  be 


494 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


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*  Since  no  deaths  were  recorded  under  the  headings  “  Following  Child-birth,”  and  “  Puerperal  diseases  of  the  breast,”  these  two  rubrics  (Nos.  140  and  141)  are 
omitted  from  the  table. 


MISCELLANEOUS  CAUSES  OF  DEATH 


495 


observed  that  the  rate  in  negroes  for  the  whole  puerperal  state  was  nearly 
double  and  for  puerperal  fever  more  than  double  those  for  whites.  The  rates 
were  considerably  higher  in  negro  than  in  white  women  for  every  rubric 
under  which  deaths  were  recorded,  with  the  exception  of  those  for  accidents 
of  pregnancy  and  vascular  affections.  The  importance  of  taking  still-births 
into  account  in  calculating  puerperal  risk-rates  is  very  obvious  from  this  table. 
Were  they  omitted,  the  divisors  would  be  too  small  for  the  population  as  a 
whole  by  7.4  per  cent  and  for  white  and  for  negro  women  by  5.9  and  12.8 
per  cent,  respectively,  with  corresponding  errors  in  the  resulting  rates. 

During  the  6-year  period  1915-1920,  of  101,539  conceptions  that  developed 
to  or  beyond  the  sixth  month  of  utero-gestation,  7,558,  or  7.4  per  cent,  were 
blighted,  and  of  approximately  the  same  number  of  women  exposed  under 
the  same  conditions  to  the  risks  of  maternity  there  died  670  or  0.65  per 
hundred.  This  combination  of  appallingly  high  rates  of  both  maternal  and 
fetal  mortality  has  been  equaled  perhaps  in  modern  times  in  no  other  medi¬ 
cal  center.  In  the  United  States  birth  registration  area  in  1918  and  in  Boston 
in  recent  years,  the  maternal  death-rates  were  considerably  higher,  but  they 
were  associated  with  still-birth  rates  not  half  so  high  (Howard,  66). 

Having  determined  the  approximately  true  maternal  risk  of  death  in  child- 
bearing  during  the  period  in  which  it  appears  that  births  (living  and  still) 
were  reported  with  a  reasonable  degree  of  completeness,  attention  may  now  be 
turned  to  the  consideration  of  rates  calculated  on  less  reliable  birth  data,  for 
the  period  between  1875  and  1914,  with  the  expectation  that  when  compared 
with  the  rates  based  upon  the  whole  female  population  it  may  be  possible 
to  form  a  more  exact  estimate  than  hitherto  possible  of  the  course  of  maternal 
mortality  during  this  period.  The  courses  of  the  rates  calculated  on  these  two 
bases  (tables  124  and  127)  show  very  distinct  correspondences.  From  both  is 
evident  that  there  were  very  marked  increases  in  the  rates  for  puerperal  fever 
between  1881  and  1889,  1891  and  1896,  and  1901  and  1905.  It  is  also  clearly 
shown  that  the  mortality  for  all  other  causes  ran  a  much  less  uneven  course 
than  did  that  for  puerperal  fever.  It  would  appear,  then,  that,  while  in  the 
intermediate  period  the  rates  from  causes  connected  with  child-birth  had  risen 
to  much  higher  levels,  the  rates  were  on  the  whole  but  little  lower  in  1915- 
1920  than  in  1875-1880.  What  gain  there  was  affected  puerperal  fever  chiefly. 
The  latter  has  been  declining  since  about  1900. 

Any  attempt  to  correlate  the  course  of  child-bed  mortality  over  the  long 
period  under  review  with  the  various  factors  known  to  influence  it  is  beset 
with  many  difficulties.  Of  prime  importance  is  the  relative  crudity  of  the 
rates  on  which  its  measurement  must  be  based.  In  this  regard,  changes  in  the 
age  distribution  of  the  female  population,  race  composition,  opportunities  for 
marriage,  variations  in  the  proportions  of  legitimate  and  illegitimate  births, 
and  those  fluctuations  in  birth-rates  which  are  dependent  upon  so  many  other 
social  circumstances,  as  well  as  upon  the  occurrence  of  epidemics,  and  which 
therefore  chiefly  determined  the  number  exposed  to  risk,  are  all  left  out  of 
consideration.  From  the  standard  of  measurement  available,  it  appears  that 
maternal  mortality  in  child-bed  has  run  in  rather  definite  waves  and  that  since 
1875,  while  to  some  extent  these  waves  and  their  peaks  have  been  associated 
with  variations  in  the  mortality  from  causes  other  than  puerperal  fever,  on 
the  whole  they  have  been  influenced  to  a  much  greater  degree  by  rises  and 
declines  in  the  rate  of  the  latter  cause.  Since  in  the  past  20  years,  when  the 


496  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

birth-rate  has  probably  varied  within  narrow  limits,  the  rate  from  puerperal 
fever  has  shown  a  perceptible  decline  and  the  rate  for  other  causes  on  the 
whole  has  fallen  but  slightly,  it  seems  likely  that  the  very  distinct  waves  of 


Table  127. — Number  of  deaths  and  rate  of  death,  per  100,000  recorded  births,  living  and 
still,  from  causes  connected  with  child-birth,  from  1875  to  1920,  inclusive. 


D  —  death.  R  =  rate. 


Year. 

Total  puerperal 
state. 

Puerperal  septicemia. 

Total  puerperal  state  excluding 
puerperal  septicemia. 

D 

R 

D 

R 

Per  cent  of 
total  puerperal 
state. 

D 

R 

Per  cent  of 
total  puerperal 
state. 

1875  . 

60 

687 

25 

286 

41.7 

35 

401 

58.3 

1876  . 

48 

612 

13 

166 

27.1 

35 

447 

72.9 

1877  . 

59 

826 

28 

392 

47.5 

31 

434 

52.5 

1878  . 

58 

864 

26 

387 

44.8 

32 

477 

55.2 

1879  . 

67 

814 

19 

231 

28.4 

48 

583 

71.6 

1880  . 

83 

877 

40 

423 

48.2 

43 

454 

51.8 

1881  . 

66 

721 

25 

273 

37.9 

41 

448 

62.1 

1882  . 

87 

1031 

38 

450 

43.7 

49 

581 

56.3 

1883  . 

82 

953 

41 

476 

50.0 

41 

476 

50.0 

1884  . 

96 

1081 

44 

495 

45.8 

52 

586 

54.2 

1885  . 

97 

1156 

48 

572 

49.5 

49 

584 

50.5 

1886  . 

111 

1319 

55 

654 

49.5 

56 

665 

50.5 

1887  . 

95 

977 

53 

545 

55.8 

42 

432 

44.2 

1888  . 

97 

1030 

52 

552 

53.6 

45 

478 

46.4 

1889  . 

87 

857 

39 

384 

44.8 

48 

473 

55.2 

1890  . 

96 

941 

34 

333 

35.4 

62 

608 

64.6 

1891  . 

118 

1163 

52 

512 

44.1 

66 

650 

55.9 

1892  . 

114 

1113 

54 

527 

47.4 

60 

586 

52.6 

1893  . 

138 

1393 

78 

787 

56.5 

60 

606 

43.5 

1894  . 

92 

911 

40 

396 

43.5 

52 

515 

56.5 

1895  . 

109 

1249 

66 

756 

60.6 

43 

493 

39.4 

1896  . 

117 

1235 

54 

570 

46.2 

63 

665 

53.8 

1897  . 

75 

789 

34 

358 

45.3 

41 

431 

54.7 

1898  . 

65 

681 

22 

231 

33.8 

43 

451 

66.2 

1899  . 

108 

1236 

27 

309 

25.0 

81 

927 

75.0 

1900  . 

126 

1350 

31 

332 

24.6 

95 

1018 

75.4 

1901  . 

126 

1331 

55 

581 

43.6 

71 

750 

56.4 

1902  . 

117 

1227 

62 

645 

53.0 

55 

572 

47.0 

1903  . 

111 

1186 

58 

620 

52.3 

53 

566 

47.7 

1904  . 

106 

1139 

59 

634 

55.7 

47 

505 

44.3 

1905  . 

102 

1045 

56 

573 

54.9 

46 

471 

45.1 

1906  . 

102 

1027 

43 

433 

42.2 

59 

594 

57.8 

1907  . 

87 

911 

43 

450 

49.5 

44 

460 

50.5 

1908  . 

92 

921 

45 

450 

48.9 

47 

471 

51.1 

1909  . 

103 

1071 

37 

385 

35.9 

66 

687 

64.1 

1910  . 

86 

805 

27 

253 

31.4 

59 

552 

68.6 

1911  . 

87 

870 

33 

330 

37.9 

54 

540 

62.1 

1912  . 

105 

869 

43 

356 

41.0 

62 

513 

59.0 

1913  . 

112 

833 

49 

364 

43.7 

63 

468 

56.3 

1914  . 

84 

615 

35 

256 

41.7 

49 

359 

58.3 

1915  . 

80 

542 

25 

169 

31.2 

55 

373 

68.8 

1916  . 

104 

637 

35 

215 

33.7 

69 

423 

66.4 

1917  . 

91 

561 

32 

197 

35.2 

59 

364 

64.8 

1918  . 

119 

722 

31 

188 

26.1 

88 

534 

74.0 

1919  . 

143 

754 

40 

211 

28.0 

103 

543 

72.0 

1920  . 

133 

659 

40 

198 

30.1 

93 

461 

69.9 

child-bed  mortality  previous  to  1875  were  associated  mainly  with  variations 
in  the  prevalence  and  severity  of  puerperal  infection. 

In  connection  with  the  high  wave  of  mortality  in  the  10-year  period  after 
1845,  it  is  of  interest  to  recall  that  Buckler  recorded  that  in  this  period  the 


MISCELLANEOUS  CAUSES  OF  DEATH 


497 


obstetric  ward  of  the  almshouse  infirmary  was  closed  a  number  of  times  on 
account  of  severe  epidemics  of  puerperal  fever.  This  affection  was  doubtless 
responsible  for  a  considerable  proportion  of  the  high  wave  of  child-bed  mor¬ 
tality  at  this  time  as  well  as  in  the  second,  third,  fourth,  seventh,  and  eighth 
decades  of  the  nineteenth  century.  With  the  exception  of  the  wave  in  the 
fourth  and  fifth  decades  just  referred  to,  high  death-rates  from  erysipelas 
and  puerperal  fever  were  not  synchronous.  The  well-known  relation  between 
scarlet  fever  and  puerperal  infection  suggests  a  comparison  in  this  connec¬ 
tion.  In  the  period  before  1875  high  rates  for  scarlet  fever  and  child-birth 
sychronized  in  1836-1837,  1844-1859,  and  1866-1874.  Between  1876  and 
1888  and  between  1901  and  1904,  rates  for  scarlet  fever  and  puerperal  fever 
were  both  relatively  high.  In  view  of  these  coincidences  and  the  established 
facts  of  the  intimate  causal  relation  between  scarlet  fever  and  puerperal  infec¬ 
tion,  the  inference  seems  warranted  that  child-bed  mortality  in  Baltimore  has 
been  strongly  influenced  by  these  two  affections. 

Perhaps  in  no  other  medical  center  in  the  United  States  have  the  extremes 
of  the  obstetric  art  been  so  well  represented  as  in  Baltimore.  From  the  time 
of  Buchanan  in  the  eighteenth  century,  the  city  has  at  no  time  lacked  able 
and  skilled  teachers  and  practitioners  of  obstetrics.  Owing  to  lack  of  facilities 
for  practical  teaching,  and  in  many  instances  to  the  poor  material  among  the 
students  of  proprietary  schools,  a  large  proportion  of  the  general  physicians 
has  been  poorly  trained  in  obstetrics.  Midwives  have  flourished  since  the 
earliest  days.  Without  schools  for  instruction  and  without  oversight  worthy 
of  the  name  they  have  been  and  are,  in  general,  ignorant  and  inept  in  the  art. 
As  late  as  1920  over  200  were  registered  as  in  practice.  In  1920,  of  18,787 
living  births,  26.1  per  cent  were  attended  by  midwives.  As  the  percentage  of 
whites  was  26.5  and  of  negroes  23.3,  it  is  evident  that  the  higher  maternal 
mortality  in  the  latter  can  not  be  attributed  to  midwives.  Baltimore  was 
fortunate  in  the  absence  of  lying-in  hospitals  in  the  days  previous  to  antisepsis, 
when  obstetric  hospitals  were  often  so  deadly.  With  the  exception  of  a  few 
beds  at  the  almshouse  infirmary  and  in  not  over  two  hospitals  in  the  city, 
obstetrical  hospitals  can  hardly  have  been  said  to  have  existed  here  before  the 
ninth  decade  of  the  nineteenth  century.  At  this  period  lying-in  hospitals  were 
established  under  careful  obstetricians  in  connection  with  the  University  of 
Maryland  and  other  medical  schools.  In  1895  the  obstetrical  wards  of  the 
Johns  Hopkins  Hospital  were  opened. 

While  no  one  of  these  hospital  services  has  ever  been  large  enough  to  accom¬ 
modate  more  than  a  small  proportion  of  parturient  women,  they  have  been 
sufficient  on  the  whole  to  care  for  all  of  the  serious  cases  needing  hospitaliza¬ 
tion  encountered  in  the  extensive  out-patient  departments  connected  with 
them.  According  to  a  conservative  estimate,  in  1917  about  one-fourth  of  all 
the  deliveries  in  the  city  occurred  under  the  care  of  these  institutions,  either 
in  the  hospitals  or  in  homes,  mostly  by  medical  students  under  competent 
supervision.  To  these  services,  to  antisepsis,  and  to  improved  opportunities 
for  obstetrical  teaching,  the  decline  in  the  maternal  death-rate  from  causes 
connected  with  child-birth  is  doubtless  largely  to  be  attributed.  It  is  evident, 
from  the  high  maternal  and  still-birth  rates  yet  obtaining,  that  obstetrical 
care  of  women  is  far  from  adequate.  The  obstetrical  clinics  established  at  the 
'writer’s  suggestion  under  the  health  department  in  1919  have  not  been  devel¬ 
oped  sufficiently  to  make  an  impression  on  the  problem. 


Chapter  XVIII. — Ill-Defined  Causes. 

Diseases  of  early  infancy;  Arthritis;  Hernia  and  Intestinal  obstruction. 

(Tables  128  to  132.) 

DISEASES  OF  EARLY  INFANCY. 

By  grouping  together  under  three  rubrics  the  deaths  classified  under  various 
statistical  headings  that  can  be  followed  for  longer  or  shorter  periods  in  the 
mortality  tables,  it  is  possible  to  trace  in  general  outline  for  100  years  the 
course  of  mortality  from  causes  peculiar  to  infancy.  These  three  rubrics  are 
convulsions,  marasmus,  and  causes  unknown  in  infants.  The  annual  rates 
for  these  are  given  in  tables  128  and  132,  respectively.  In  regard  to  age  these 
rates  are  crude,  and  in  regard  to  cause  they  are  inexact,  for  it  has  been  neces¬ 
sary  to  use  as  divisor  the  total  estimated  population,  and  the  dividends  are 
subject  to  errors  of  both  inclusion  and  omission.  It  is  likely,  however,  that 
these  have  tended  to  balance  each  other.  These  data  have  been  submitted  to 
all  possible  checks,  the  most  important  of  which  was  the  critical  examination 
of  a  large  number  of  the  original  death  certificates  of  1875  and  other  years. 
Here  it  was  ascertained  that,  with  few  exceptions,  the  deaths  certified  under 
the  headings  included  in  these  rubrics  occurred  in  individuals  in  the  first  two 
years  of  life  and,  in  the  overwhelming  majority  of  instances,  in  the  early 
months  of  infancy.  The  same  was  found  to  hold  true  of  the  more  definitive 
rubrics  into  which  these  various  headings  finally  merged  in  the  international 
classification  in  and  after  1899.  Further  justification  of  the  use  of  these  data 
in  this  connection  will  appear  from  the  following  analysis : 

CONVULSIONS. 

This  rubric  (table  128),  appearing  annually  without  intermission  since 
1812,  was  characterized  by  rates  particularly  high  from  1812  to  1840  and 
from  1866  to  1892.  While  it  probably  included  some  deaths  of  infants,  of 
older  children,  and  even  of  adults  with  convulsions  associated  with  uraemia, 
whooping-cough,  scarlet  fever,  and  meningitis,  from  the  relative  magnitude 
of  the  rates  in  the  earlier  years  it  seems  improbable  that  errors  from  these 
sources  were  large.  It  was  apparently  synonymous  with  convulsions  of  infants 
(later  rubric  71),  into  which  it  merged  in  1899. 

MARASMUS. 

(Table  128.) 

This  term  is  used  for  this  rubric  because  it  was  the  first  member  of  this 
category  of  causes  of  death  to  appear  in  the  statistical  nosology.  Except  for 
a  few  years  in  the  fifth  decade  of  the  nineteenth  century,  it  was  annually 
credited  with  a  considerable  number  of  deaths  from  1820  to  1898,  when  it  dis¬ 
appeared.  Next  to  appear  was  debility  in  1851.  To  this  heading  was  ascribed 
498 


Table  128. — Number  o]  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from  convulsions,  ma¬ 
rasmus,  rheumatism  and  gout,  senility,  hernia  and  intestinal  obstruction,  and  appendicitis  and  ty¬ 
phlitis,  from  1812  to  1920,  inclusive. 


D  =  death.  R  =  rate. 


Year. 

Con¬ 

vulsions. 

Ma¬ 

rasmus.* 

Rheumatism  and  gout. 

Senility. 

Hernia  and 
intestinal 
obstruction. 

Appendicitis 
and  typhlitis. 

Chronic 

rheumatism  and 
gout. 

Imfiamma- 
tory  rheuma¬ 
tism. 

Total. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1812.. 

64 

156 

3 

7 

3 

7 

42 

103 

1813.. 

115 

269 

1 

2 

1 

2 

62 

145 

1814. . 

80 

179 

•  •  •  • 

2 

4 

2 

4 

69 

154 

1815.. 

98 

210 

•  •  •  • 

2 

4 

2 

4 

83 

178 

1816.. 

91 

186 

•  •  •  • 

6 

12 

6 

12 

54 

111 

1817.. 

98 

192 

•  •  •  • 

3 

6 

3 

6 

57 

112 

1818.. 

115 

216 

•  •  •  • 

1 

2 

1 

2 

62 

117 

1819.. 

92 

166 

•  •  •  • 

6 

11 

2 

4 

8 

14 

77 

139 

1820.. 

90 

156 

6 

10 

2 

3 

2 

3 

78 

135 

1821.. 

84 

139 

15 

25 

5 

8 

5 

8 

93 

154 

1822.. 

83 

132 

46 

73 

11 

18 

1 

2 

12 

19 

87 

138 

1823. . 

60 

92 

13 

20 

9 

14 

9 

14 

69 

105 

1824. . 

46 

68 

1 

1 

4 

6 

4 

6 

72 

106 

1825.. 

47 

66 

35 

49 

2 

3 

2 

3 

69 

97 

1826. . 

55 

75 

10 

14 

4 

5 

1 

1 

5 

7 

107 

145 

1827.. 

63 

82 

27 

35 

4 

5 

3 

4 

7 

9 

71 

93 

1828.. 

68 

86 

27 

34 

2 

3 

•  •  •  • 

•  •  •  • 

2 

3 

93 

117 

1829.. 

68 

82 

89 

108 

3 

4 

•  •  •  • 

•  •  •  • 

3 

4 

107 

130 

1830. . 

70 

82 

82 

96 

5 

6 

•  •  •  • 

•  •  •  • 

5 

6 

94 

110 

1831.. 

78 

88 

32 

36 

8 

9 

1 

1 

9 

10 

104 

117 

1832.. 

89 

97 

55 

60 

7 

8 

1 

1 

8 

9 

164 

178 

1833.. 

110 

115 

27 

28 

2 

2 

2 

2 

4 

4 

87 

91 

1834. . 

93 

94 

17 

17 

2 

2 

1 

1 

3 

3 

126 

127 

1835. . 

89 

87 

30 

29 

2 

2 

•  •  •  • 

•  •  •  • 

2 

2 

120 

117 

1836.. 

92 

87 

27 

25 

•  • 

•  • 

2 

2 

2 

2 

137 

129 

1837.. 

90 

82 

32 

29 

7 

6 

•  •  •  • 

•  «  •  • 

7 

6 

93 

85 

1838.. 

89 

79 

30 

26 

2 

2 

3 

3 

5 

4 

94 

83 

1839. . 

68 

58 

18 

15 

4 

3 

2 

2 

6 

5 

118 

101 

1840.. 

55 

45 

3 

2 

7 

6 

2 

2 

9 

7 

96 

79 

1841.. 

84 

67 

5 

4 

8 

6 

•  •  •  • 

•  •  •  • 

8 

6 

98 

78 

1842.. 

84 

65 

5 

4 

11 

9 

1 

1 

12 

9 

98 

76 

1843. . 

58 

44 

2 

2 

5 

4 

4 

3 

9 

7 

120 

90 

1844.. 

73 

53 

•  •  •  • 

•  •  • 

6 

4 

1 

1 

7 

5 

93 

68 

1845.. 

81 

57 

1 

1 

1 

1 

6 

4 

7 

5 

97 

69 

1846.. 

73 

50 

•  •  •  • 

•  •  • 

2 

1 

4 

3 

6 

4 

129 

88 

1847.. 

81 

54 

•  •  •  • 

•  •  • 

5 

3 

2 

1 

7 

5 

144 

96 

1848.. 

106 

69 

•  •  •  • 

•  •  • 

4 

3 

5 

3 

9 

6 

156 

101 

1849. . 

97 

61 

1 

1 

8 

5 

1 

1 

9 

6 

171 

107 

1850. . 

92 

56 

•  •  •  • 

•  •  • 

3 

2 

6 

4 

9 

5 

140 

85 

2 

1 

•  •  •  • 

1851.. 

99 

59 

1 

1 

8 

5 

8 

5 

156 

93 

3 

2 

1852. . 

102 

59 

•  •  •  • 

11 

6 

11 

6 

174 

100 

4 

2 

1853. . 

136 

76 

30 

17 

7 

4 

7 

4 

180 

101 

1 

1 

1854. . 

116 

63 

184 

100 

7 

4 

7 

4 

184 

100 

7 

4 

1855. . 

136 

72 

18 

10 

13 

7 

13 

7 

202 

107 

3 

2 

1856. . 

127 

66 

8 

4 

11 

6 

11 

6 

188 

97 

2 

1 

1857.. 

92 

46 

•  •  •  • 

•  •  • 

15 

8 

15 

8 

185 

93 

4 

2 

1858. . 

134 

66 

1 

•  •  • 

8 

4 

8 

4 

211 

104 

1 

•  •  •  • 

1859. . 

106 

51 

5 

2 

13 

6 

13 

6 

160 

77 

•  •  •  • 

•  •  •  • 

1860. . 

112 

52 

2 

1 

11 

5 

11 

5 

215 

100 

4 

2 

1861. . 

106 

48 

4 

2 

11 

5 

11 

5 

215 

98 

3 

1 

1862. . 

98 

43 

6 

3 

21 

9 

21 

9 

190 

84 

2 

1 

1863.. 

103 

45 

31 

13 

26 

11 

26 

11 

204 

88 

5 

2 

1864.. 

91 

38 

33 

14 

21 

9 

21 

9 

202 

85 

1 

•  •  •  • 

1865. . 

100 

41 

22 

9 

23 

• 

9 

23 

9 

167 

69 

2 

1 

*  Including  inanition,  debility,  asthenia,  asphyxia  neonatorum,  atalectasis  pulmonum,  atrophy  and 
premature  birth.  After  1899  these  affections  have  been  classified  under  congenital  malformations,  con¬ 
genital  debility,  inanition  and  other  diseases  peculiar  to  infancy. 


(499) 


Table  12S. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from  convulsions,  ma¬ 
rasmus,  rheumatism  and  gout,  etc. — Continued. 


D  =  death.  R  =  rate. 


Y  ear. 

Con¬ 

vulsions. 

Ma¬ 

rasmus.* 

Rheumatism  and  gout. 

Senility. 

Hernia  and 
intestinal 
obstruction. 

Appendicitis 
and  typhlitis. 

Chronic 

rheumatism  and 
gout. 

Imflamma- 
tory  rheuma¬ 
tism. 

Total. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1866. . 

202 

81 

46 

19 

20 

8 

20 

8 

219 

88 

2 

1 

1867.. 

209 

82 

22 

9 

12 

5 

12 

5 

188 

74 

3 

1 

1868. . 

301 

116 

26 

10 

28 

11 

28 

11 

199 

76 

1 

•  •  •  • 

1869. . 

289 

108 

67 

25 

49 

18 

49 

18 

229 

86 

1 

•  •  •  • 

1870.. 

298 

109 

74 

27 

34 

12 

34 

12 

327 

120 

2 

I 

1871. . 

312 

112 

46 

16 

38 

14 

38 

14 

299 

107 

•  •  •  • 

•  •  •  • 

1872. . 

305 

107 

33 

12 

53 

19 

53 

19 

314 

no 

10 

4 

1873. . 

267 

92 

53 

18 

62 

21 

62 

21 

335 

115 

9 

3 

1874.. 

328 

110 

63 

21 

48 

16 

48 

16 

289 

97 

8 

3 

1875.. 

308 

73 

475 

151 

53 

17 

53 

17 

211 

69 

34 

11 

1876.. 

361 

116 

533 

171 

50 

16 

50 

16 

240 

77 

26 

8 

1877.. 

306 

96 

554 

174 

46 

14 

.... 

46 

14 

211 

66 

23 

7 

1878. . 

294 

91 

512 

158 

6 

2 

16 

5 

22 

7 

212 

65 

23 

7 

1879. . 

323 

97 

538 

162 

3 

1 

28 

8 

31 

9 

255 

77 

25 

8 

1880. . 

367 

108 

622 

184 

6 

2 

26 

8 

32 

9 

251 

74 

30 

9 

1881. . 

419 

121 

620 

179 

7 

2 

32 

9 

39 

11 

251 

73 

19 

6 

1 

1882. . 

362 

103 

590 

167 

4 

1 

20 

6 

24 

7 

305 

86 

36 

10 

•  •  •  • 

1883. . 

388 

108 

625 

174 

4 

1 

17 

5 

21 

6 

259 

72 

20 

6 

2 

1 

1884. . 

342 

93 

680 

185 

10 

3 

19 

5 

29 

8 

282 

77 

37 

10 

3 

1 

1885. . 

366 

98 

672 

180 

14 

4 

15 

4 

29 

8 

291 

78 

34 

9 

3 

1 

1886.. 

319 

84 

755 

198 

15 

4 

32 

8 

47 

12 

248 

65 

28 

7 

•  •  •  • 

•  •  •  • 

1887. . 

348 

89 

690 

177 

18 

5 

20 

5 

38 

10 

291 

75 

30 

8 

2 

1 

1888. . 

304 

72 

724 

173 

24 

6 

23 

5 

47 

11 

318 

76 

43 

10 

4 

1 

1889.. 

289 

68 

803 

188 

22 

5 

19 

4 

41 

10 

313 

73 

54 

13 

1 

•  •  •  • 

1890. . 

311 

72 

793 

182 

32 

7 

24 

6 

56 

13 

350 

81 

58 

13 

6 

1 

1891. . 

352 

80 

837 

189 

25 

6 

11 

2 

36 

8 

431 

98 

55 

12 

6 

1 

1892. . 

334 

74 

785 

175 

17 

4 

21 

5 

38 

8 

417 

93 

58 

13 

9 

2 

1893. . 

259 

57 

840 

184 

28 

6 

24 

5 

52 

11 

329 

72 

53 

12 

13 

3 

1894.. 

267 

58 

775 

167 

49 

11 

5 

1 

54 

12 

323 

70 

40 

9 

22 

5 

1895. . 

293 

62 

828 

176 

37 

8 

4 

1 

41 

9 

317 

67 

41 

9 

18 

4 

1896. . 

285 

60 

799 

167 

45 

9 

7 

1 

52 

11 

300 

63 

52 

11 

25 

5 

1897. . 

252 

52 

815 

168 

40 

8 

4 

1 

44 

9 

255 

52 

76 

16 

34 

7 

1898. . 

301 

61 

910 

185 

48 

10 

1 

•  •  •  • 

49 

10 

362 

73 

54 

11 

34 

7 

1899. . 

221 

44 

761 

152 

64 

13 

•  •  •  • 

•  •  •  • 

64 

13 

358 

72 

57 

11 

52 

10 

1900. . 

277 

55 

919 

181 

41 

8 

•  •  •  • 

•  •  •  • 

41 

8 

339 

67 

75 

15 

63 

12 

1901. . 

332 

65 

951 

185 

20 

4 

12 

2 

32 

6 

373 

73 

90 

18 

57 

11 

1902. . 

168 

32 

1049 

201 

17 

3 

36 

7 

53 

10 

315 

60 

87 

17 

66 

13 

1903. . 

136 

26 

896 

170 

10 

2 

48 

9 

58 

11 

258 

49 

81 

15 

60 

11 

1904. . 

140 

26 

895 

168 

11 

2 

74 

14 

85 

16 

236 

44 

68 

13 

77 

14 

1905. . 

146 

27 

903 

167 

9 

2 

53 

10 

62 

11 

231 

43 

64 

12 

52 

10 

1906. . 

127 

23 

914 

167 

18 

3 

64 

12 

82 

15 

222 

41 

70 

13 

63 

12 

1907. . 

156 

28 

928 

168 

13 

2 

69 

12 

82 

15 

276 

50 

87 

16 

55 

10 

1908. . 

110 

20 

865 

154 

13 

2 

78 

14 

91 

16 

250 

45 

93 

17 

57 

10 

1909. . 

97 

17 

818 

144 

20 

4 

59 

10 

79 

14 

216 

38 

105 

19 

61 

11 

1910. . 

114 

20 

762 

133 

15 

3 

50 

9 

65 

11 

190 

33 

92 

16 

66 

12 

1911. . 

63 

11 

691 

119 

14 

2 

50 

9 

64 

11 

166 

29 

83 

14 

78 

13 

1912. . 

67 

11 

909 

156 

16 

3 

35 

6 

5l\ 

9 

213 

36 

98 

17 

59 

10 

1913. . 

61 

10 

812 

138 

37 

6 

35 

6 

72  j 

12 

166 

28 

118 

20 

63 

11 

1914. . 

48 

8 

813 

136 

39 

7 

36 

6 

75 

13 

170 

29 

111 

19 

80 

13 

1915. . 

31 

5 

696 

116 

17 

3 

40 

7 

57 

9 

96 

16 

87 

14 

69 

11 

1916. . 

30 

5 

720 

119 

10 

2 

24 

4 

34 

6 

85 

14 

93 

15 

76 

13 

1917. . 

17 

3 

726 

119 

14 

2 

52 

8 

66 

11 

86 

14 

no 

18 

96 

16 

1918. . 

17 

3 

837 

136 

11 

2 

44 

7 

55 

9 

105 

17 

111 

18 

79 

13 

1919. . 

18 

3 

756 

105 

14 

2 

36 

5 

50 

7 

63 

9 

109 

15 

91 

13 

1920. . 

16 

2 

856 

117 

13 

2 

40 

5 

) 

53i 

1 

7 

58 

8 

■ 

102 

14 

96 

13 

*  Including  inanition,  debility,  asthenia,  asphyxia  neonatorum,  atalectasis  pulmonum,  atrophy  and 
premature  birth.  After  1899  these  affections  have  been  classified  under  congenital  malformations,  con¬ 
genital  debility,  inanition  and  other  diseases  peculiar  to  infancy. 

(500) 


MISCELLANEOUS  CAUSES  OF  DEATH 


501 


a  considerable  number  of  deaths  in  certain  years  of  the  sixth,  seventh,  and 
eighth  decades  of  the  nineteenth  century.  By  1875  it  was  comparatively 
insignificant,  and  in  1899  it  was  absorbed  in  the  new  rubric,  congenital 
debility.  Inanition  entered  the  statistical  nosology  in  1873,  and  from  1875 
to  1909  to  it  a  large  number  of  deaths  was  annually  attributed.  To  asthenia, 
atrophy,  and  asphyxia  (the  latter  synonymous  with  atalectasis  pulmonum) 
deaths  were  credited  from  1875  to  1898.  Appearing  first  in  1875,  premature 
birth  continued  as  an  important  assigned  cause  of  death  until  1898.  All  of 
these  rubrics  gave  place  in  1899  to  the  three  rubrics  embracing  causes  of 
death  other  than  congenital  malformations  peculiar  to  early  infancy.  Since 
with  few  exceptions  deaths  from  congenital  malformations  occur  shortly  after 
birth,  and  since,  except  under  hydrocephalus,  which  in  the  earlier  years  held 
an  entirely  different  significance  (see  meningitis),  this  cause  can  be  traced 
but  rarely,  the  conclusion  is  forced  that  before  1899  they  were  included  under 
one  of  the  headings  of  the  group  under  discussion.  The  great  and  steady 
increase  in  the  importance  of  the  rubric  congenital  malformations  since  its 
introduction  in  1899  can  only  be  explained  by  change  in  custom  of  classifica¬ 
tion  of  deaths.  For  these  reasons  it  has  seemed  necessary  to  include  this 
rubric  also.  Indeed,  it  is  not  unlikely  that  most  of  the  deaths  in  early  infancy 
are  in  a  broad  sense  due  to  congenital  defects  which  render  extra-uterine 
existence  under  adverse  conditions  impracticable. 

DEATHS  OF  INFANTS  FROM  CAUSES  UNKNOWN. 

From  table  132  it  will  be  observed  that  this  rubric  appeared  first  in  1820, 
when  distinction  was  made  between  deaths  in  infants  and  in  adults  from 
unknown  causes.  From  the  much  higher  rates  which  from  1820  were  ascribed 
consistently  under  this  heading  to  infants,  it  is  reasonable  to  suppose  that 
the  same  held  good  before  this  date.  High  rates  characterized  this  rubric  until 
1875,  after  which,  with  the  growing  importance  of  the  other  rubrics  under 
consideration,  it  gradually  declined  to  insignificance,  to  disappear  completely 
after  1893.  After  all,  when  obvious  congenital  defects  and  infections  (syphilis, 
umbilical-cord  infection,  cholera  infantum,  and  the  eruptive  and  respiratory 
diseases)  are  excluded,  most  deaths  of  infants  are  really  due  to  causes  yet 
unknown,  and  former  generations  were  not  unwise  in  declining  to  accept  names 
as  true  explanations.  The  rates  for  these  three  rubrics,  convulsions,  marasmus, 
and  causes  unknown,  separately  and  combined  as  averaged  for  5-year  periods, 
are  given  in  table  129.  It  is  obvious  at  a  glance  that  no  one  or  two  of  these 
rubrics  can  be  taken  as  the  measure  of  the  course  of  mortality  for  the  causes 
under  consideration.  Taking  the  total  for  all  three  rubrics,  it  is  found  that 
from  1821  to  1920  the  curve  is  a  fairly  consistent  one.  Starting  at  371  for 
the  period  1821-1825,  the  rate  was  well  over  500  during  the  next  three  quin¬ 
quennia.  From  1841  to  1890,  the  rate,  except  for  the  period  1871-1875,  did 
not  depart  far  from  400.  There  was  a  slight  fall  from  380  for  1886-1890 
to  357  for  1896-1900.  No  material  change  was  brought  about  in  the  rate  by 
the  falling  out  after  1875  of  causes  unknown  as  an  important  rubric.  The 
rubric  marasmus  immediately  rose  correspondingly. 

If  the  assumptions  and  inferences  upon  which  these  rubrics  have  been  set 
up  are  in  the  main  valid,  the  fluctuations  in  the  total  rate  between  1820  and 
1900  are  probably  no  greater  than  would  be  expected  from  errors  of  classifica¬ 
tion  of  deaths  and  variations,  due  to  changes  in  the  birth-rate,  in  the  propor- 


502  PUBLIC  HEALTH  ADMINISTRATION",  ETC.,  IN'  BALTIMORE 


tional  distribution  in  the  population  of  individuals  of  the  restricted  age-group 
under  consideration.  Since  1900,  however,  a  very  considerable  but  gradual 
decline  has  taken  place.  From  357  for  the  period  1896-1900,  the  rate  fell  to 
122  for  that  ending  in  1920.  In  the  20  years  since  1900  the  rubrics  of  classifica¬ 
tion  are  clear-cut  and  no  ambiguity  as  to  their  meaning  and  content  befogs 
the  question.  All  the  evidence  at  hand  indicates  that  the  birth-rate  can  have 
varied  but  little  during  this  period.  Since  deaths  from  the  causes  now  under 
discussion  occur  almost  exclusively  in  the  first  year  of  life  and  include  a  very 
large  proportion  of  deaths  from  all  causes  (40  to  50  per  cent)  in  this  age- 
period,  there  should  be  a  close  correspondence  between  the  course  of  the  rates 
just  discussed  and  the  percentage  of  deaths  under  1  year  of  age  to  the  total 
deaths  at  all  ages.  As  a  matter  of  fact  (table  138),  the  latter  varied  within 


Table  129. — Average  rate  of  death,  per  100,000  living  inhabitants,  by  6-year  periods, 
from  certain  diseases  of  early  infancy,  from  1812  to  1920,  inclusive. 


Periods. 

Convulsions. 

Marasmus.* 

Total. 

Causes  unknown 
(infantile). 

Total. 

Periods. 

Convulsions. 

Marasmus.* 

Total. 

Causes  unknown 

(infantile). 

Total. 

1812-15 

163 

•  •  •  • 

163 

•  •  •  • 

163 

1866-70 

99 

22 

121 

337 

458 

1816-20 

•  •  •  • 

183 

•  •  •  • 

183 

•  •  •  • 

183 

1871-75 

•  •  •  • 

99 

57 

156 

213 

369 

1821-25 

•  •  •  • 

99 

34 

133 

238 

371 

1876-80 

•  •  •  • 

102 

275 

377 

15 

392 

1826-30 

•  •  •  • 

81 

57 

139 

400 

539 

1881-85 

•  •  •  • 

105 

287 

392 

10 

402 

1831-35 

•  •  •  • 

96 

34 

130 

443 

573 

1886-90 

•  •  •  • 

77 

299 

376 

4 

380 

1836-40 

•  •  •  • 

70 

20 

89 

444 

533 

1891-95 

•  •  •  • 

66 

291 

357 

f4 

361 

1841-45 

•  •  •  • 

57 

2 

59 

370 

429 

1896-1900  .. 

54 

303 

357 

•  •  •  • 

357 

1846-50 

•  •  •  • 

58 

•  •  •  • 

58 

363 

421 

1901-05 

•  •  •  • 

35 

178 

213 

•  •  •  • 

213 

1851-55 

•  •  •  • 

66 

26 

92 

322 

414 

1906-10 

•  •  •  • 

22 

153 

175 

•  •  •  • 

175 

1856-60 

•  •  •  • 

56 

2 

58 

336 

394 

1911-15 

•  •  •  • 

9 

133 

142 

•  •  •  • 

142 

1861-65 

.... 

43 

9 

52 

327 

379 

1916-20 

.... 

3 

119 

122 

.... 

122 

*  Including  inanition,  debility,  asthenia,  asphyxia  neonatorum,  atalectasis  pulmonum, 
atrophy,  and  premature  birth.  After-  1899,  these  affections  have  been  classified  under 
congenital  malformations,  congenital  debility,  inanition,  and  other  diseases. 

f  Averaged  for  three  years  only. 

comparatively  narrow  limits  between  1816-1820  and  1886-1890,  and  for  the 
latter  period  stood  at  29  per  cent.  From  this  time  the  decline  was  steadily  to 
16  per  cent  for  1916-1920,  a  decrease  of  45  per  cent.  In  the  same  space  of 
time,  i.  e.,  since  1890,  the  decline  in  the  rate  for  causes  peculiar  to  infancy  was 
about  63  per  cent.  When  due  allowance  is  made  for  crudeness  of  the  basis 
of  comparison  the  correlation  is  strikingly  high.  An  apter  comparison  is 
that  between  the  averaged  crude  rates  and  the  rates  specific  for  the  first  year 
of  life  for  this  group  of  affections  determined  for  the  census  years.  These  are 
found  to  be  for  1850,  11,049;  for  1860,  12,726;  for  1880,  12,041;  for  1890, 
11,686;  for  1900,  11,029;  for  1910,  8,556;  and  for  1920,  5,871.  Between 
1850  and  1900  the  decline  in  the  average  crude  rate  was  15  per  cent  and  the 
change  in  the  specific  rate  was  negligible,  while,  since  1900,  the  former  fell 
by  65  and  the  latter  by  46  per  cent.  All  things  considered,  the  correspondence 
is  close. 

Whatever  doubt  may  be  thrown  on  the  accuracy  of  the  picture  of  the  course 
of  mortality  from  this  group  of  causes  during  the  previous  80  years,  when  the 


MISCELLANEOUS  CAUSES  OF  DEATH 


503 


rates  for  the  initial  and  closing  periods  were  approximately  the  same,  there 
can  be  no  question  that  during  the  last  20  years  the  rates  must  reflect  actual 
experience  with  a  reasonable  degree  of  accuracy.  While  the  assumption  that 
fatal  syphilis  was  more  common  in  the  earlier  years  may  not  be  successfully 
combated,  and  that  in  the  period  of  the  prevalence  of  certain  diseases  in  severe 
and  often  epidemic  states  premature  births  were  probably  more  common  must 
be  acknowledged,  more  adequate  explanations  than  these  are  needed  to  account 
for  the  recent  sensible  drop  in  mortality  from  a  group  of  affections  in  the 
causation  of  which  infectious  processes  other  than  syphilis  play  a  subordinate 
role. 

On  the  other  hand,  in  the  period  of  falling  rates  there  have  been  in  play,  and 
with  a  correspondingly  increasing  intensity  of  activity,  a  set  of  influences 
rightly  designed  to  accomplish  this  very  purpose.  In  so  far  as  deaths  from 
causes  peculiar  to  infancy  are  preventable,  the  result  is  reached  by  improvement 
in  the  care  of  infants  before  and  after  birth.  It  was  in  this  20-year  period 


Table  130. — Number  of  deaths  and  rate  of  death,  per  100,000  live-births,  from  certain  diseases 
of  early  infancy  and  number  of  live-briths,  according  to  color  and  sex,  for  1920. 

D  =  death.  R  =  rate. 


• 

Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

Number  of  live-births 

18787 

15934 

8159 

7775 

2853 

1436 

1417 

Convulsions  . 

16 

85 

12 

75 

8 

98 

4 

51 

4 

140 

3 

209 

1 

71 

Congenital  malforma- 

tions  . 

190 

1011 

157 

985 

94 

1152 

63 

810 

33 

1157 

16 

1114 

17 

1200 

Congenital  debility.. 

510 

2715 

394 

2473 

220 

2696 

174 

2238 

116 

4066 

65 

4526 

51 

3599 

Other  diseases  pecu- 

liar  to  early  in- 

fancy  . 

155 

825 

121 

759 

69 

846 

52 

669 

34 

1192 

21 

1462 

13 

917 

Lack  of  care . 

1 

5 

1 

6 

1 

13 

•  Total  . 

872 

4642 

685 

4299 

391 

4792 

294 

3781 

187 

6555 

105 

7312 

82 

5787 

that  obstetric  teaching  and  practice  improved,  obstetrical  facilities  were 
extended,  modern  pediatrics  with  dispensaries  and  hospital  care  developed, 
and  instruction  of  mothers  through  the  Visiting  Nurse  and  the  Babies  Milk 
Fund  Associations  has  been  carried  out  on  an.  ever-increasing  scale.  Owing 
to  the  exposure  of  the  deadly  foundling  asylums  by  a  special  committee,  since 
1914  the  doors  of  these  institutions  have  been  closed  to  infants  under  6 
months  of  age.  A  class  of  babies  heretofore  condemned  to  almost  certain 
death  have  thus  been  retained  in  the  care  of  their  mothers  during  the  most 
risky  period  of  existence. 

In  the  same  period  the  racial  complex  of  the  population  has  undergone 
changes  favorable  to  decrease  in  infant  mortality.  The  proportion  of  negroes 
to  whites  has  decreased,  and  the  ratio  of  race  stocks — Polish  Jews,  Poles,  and 
Italians — among  whom  infant  suckling  is  the  rule — has  increased.  On  the 
basis  of  the  live-births  reported,  rates  specific  for  sex  and  color  for  the  rubrics 
covering  deaths  really  peculiar  to  infants  in  1920  are  given  in  table  130. 


504  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


From  this  table  it  is  clear  that  not  only  for  the  total  of  all  the  rubrics,  but  for 
each  separate  rubric  where  the  figures  are  large  enough  to  be  significant,  the 
rates  were  much  higher  among  negroes  than  among  whites  and  among  males 
than  among  females.  Of  the  total  number  of  those  deaths,  the  percentage 
for  each  rubric  that  occurred  within  the  first  year  of  life  was  as  follows : 
convulsions,  81;  congenital  malformations,  95;  congenital  debility,  98;  other 
diseases  of  infants  and  lack  of  care,  each,  100.  There  occurred  during  the 
first  month  of  life  of  the  total  number  dying  under  1  year  of  age,  of  con¬ 
vulsions,  31  per  cent;  of  congenital  malformations,  69  per  cent;  of  congenital 
debility,  85  per  cent;  of  other  diseases  of  infancy,  97.4  per  cent;  and  of  lack 
of  care,  100  per  cent.  There  can  be  little  doubt,  therefore,  that  this  group  of 
causes  of  death  corresponds  to  those  that  have  been  discussed  above. 

ARTHRITIS. 

Deaths  have  been  classified  in  the  mortality  tables  as  due  to  gout  or  rheuma¬ 
tism,  either  chronic  or  unqualified,  with  a  single  exception,  in  each  year  since 
1812.  To  acute  rheumatism  were  assigned  a  few  deaths  in  occasional  years 


Table  131. — Average  rate  of  death,  per  100,000  living  inhabitants,  by  5-year  periods, 
from  rheumatism  and  gout,  senility,  hernia  and  intestinal  obstruction,  and  appen¬ 
dicitis,  from  1812  to  1920,  inclusive. 


Periods. 

Rheumatism  and 
gout. 

Hernia  and  intestinal 
obstruction. 

Appendicitis  and 
typhlitis- 

Periods. 

Rheumatism  and 
gout. 

Hernia  and  Intestinal 
obstruction. 

Appendicitis  and 

typhlitis. 

Chronic  rheuma¬ 
tism  and  gout. 

Inflammatory 

rheumatism. 

Total. 

Chronic  rheuma¬ 
tism  and  gout. 

Inflammatory 

rheumatism. 

Total. 

1812-15 

5 

5 

1866-70 

•  •  •  • 

11 

•  •  •  • 

11 

1 

•  •  •  • 

1816-20 

•  •  •  • 

7 

1 

8 

1871-75 

•  •  •  • 

17 

•  •  •  • 

17 

4 

•  •  •  • 

1821-25 

•  •  •  • 

10 

•  •  •  • 

10 

1876-80 

•  •  •  • 

7 

4 

11 

8 

•  •  •  • 

1826-30 

•  •  •  • 

5 

1 

6 

1881-85 

•  •  •  • 

2 

6 

8 

8 

•  •  •  • 

1831-35 

•  •  •  • 

5 

1 

6 

1886-90 

•  •  •  • 

5 

6 

11 

10 

1 

1836-40 

•  •  •  • 

3 

2 

5 

1891-95 

•  •  •  • 

7 

3 

10 

11 

3 

1841-45 

•  •  •  • 

5 

2 

7 

1896-1900  .. 

9 

1 

10 

13 

8 

1846-50 

•  •  •  • 

3 

2 

5 

•  •  •  • 

1901-05 

•  •  •  • 

3 

8 

11 

15 

12 

1851-55 

•  •  •  • 

5 

•  •  •  • 

5 

2 

1906-10 

•  •  •  • 

3 

11 

14 

16 

11 

1856-60 

•  •  •  • 

6 

•  •  •  • 

6 

1 

1911-15 

•  •  •  • 

4 

7 

11 

17 

12 

1861-65 

•  •  •  • 

9 

.... 

9 

1 

1916-20 

.... 

2 

6 

8 

16 

13 

between  1819  and  1850.  This  rubric  disappeared  completely  from  1851  to 
1878.  It  reappeared,  however,  in  1878,  and  with  the  exception  of  two  years 
it  has  been  credited  with  deaths  in  each  succeeding  year.  The  annual  data 
for  these  two  rubrics  are  presented  in  table  128.  These  do  not  include  deaths 
ascribed  to  disease  of  the  hip-joint,  the  knee,  and  the  spinal  vertebras,  which 
have  elsewhere  been  classified  under  tuberculosis.  They  do  include,  however, 
deaths  from  all  other  anatomical  and  etiological  varieties  of  arthritis.  It  has  not 
been  possible  to  distinguish  between  true  gout  and  other  forms  of  arthritis, 
and  it  is  evident  from  the  table  that  not  until  1901  and  after  is  any  significant 
distinction  between  acute  and  chronic  arthritis  warranted. 

Taking  the  recorded  figures  at  their  face  value,  and  using  for  convenience 
rates  averaged  for  5-year  periods  (table  131),  the  mortality  from  presumably 


MISCELLANEOUS  CAUSES  OF  DEATH 


505 


non-tuberculous  arthritis  as  a  whole  may  be  studied  with  some  profit.  Up 
until  1865  an  average  rate  of  from  5  to  7  obtained  in  each  period,  except  in 
1816-1820,  1821-1825,  and  1861-1865,  when  it  was  8,  10,  and  9,  respectively. 
After  1865  the  rate  held  remarkably  steady  at  10  or  11  in  7  out  of  11  periods. 
It  fell  to  8  in  the  periods  1881-1885  and  1916-1920,  and  rose  to  17  and  to 
14,  respectively,  between  1871  and  1875  and  1906  and  1910.  It  will  be  noted 
that  the  rate  was  the  same  in  1816-1820  and  1916-1920.  In  the  20  years 
1901-1920,  during  which  it  may  be  followed  separately  with  some  degree  of 
certainty,  the  rate  for  acute  rheumatism  varied  from  6  to  11,  relatively  wide 
extremes.  This  suggests  that  the  fluctuations  noted  in  the  total  rate  in  earlier 
years  may  have  been  due,  in  large  measure  at  least,  to  exacerbations  in  the 
mortality  of  acute  arthritis  of  the  type  commonly  known  as  acute  inflamma¬ 
tory  rheumatism. 

HERNIA  AND  INTESTINAL  OBSTRUCTION. 

Deaths  under  this  rubric  can  not  be  traced  in  the  mortality  tables  before 
1850,  and  for  many  subsequent  years  most  of  the  small  mortality  from  these 
causes  was  classified  under  hernia.  It  was  not  until  1875  that  the  annual  rates 
(table  128)  became  significant.  Beginning  in  this  year  with  a  rate  of  11,  and 
fluctuating  during  the  following  13  years  between  6  and  10,  the  annual  rate 
reached  13  in  1889.  In  only  two  years  since  this  date  did  the  rate  again  fall 
below  11.  After  1899  the  course  of  the  annual  rates  follows  definite  short 
waves  of  irregular  length,  with  rates  in  the  peak  year  of  18  in  1901,  19  in 
1909,  20  in  1913,  and  18  in  1917  and  1918. 

When  averaged  for  5-year  periods  (table  131),  the  rate  was  8  from  1876  to 
1885,  10  from  1886  to  1890,  11  from  1891  to  1895,  and  13  from  1896  to 
1900.  During  the  next  20  years,  a  period  of  more  discriminating  classifica¬ 
tion  of  deaths  and  of  more  frequent  surgical  intervention,  with  perfected 
technique  in  this  group  of  affections  for  which  mechanical  measures  offer 
almost  the  sole  hope  of  prevention  and  cure,  the  rate  as  averaged  for  5-year 
periods  has  remained  almost  stationary — from  15  to  17.  At  first  sight  it 
would  appear  that  rates  of  this  level  represent  the  natural  inevitable  mor¬ 
tality  from  this  group  of  causes.  Analysis  of  the  facts  and  probabilities 
of  the  case  shows  that  this  view  is  untenable.  In  the  first  place,  while  improve¬ 
ments  in  diagnosis  and  classification  have  undoubtedly  relegated  to  other 
rubrics  many  deaths  which  before  1899  would  have  been  classified  under  this 
heading,  it  is  certain  that  many  deaths  following  acute  intestinal  obstruction 
within  a  few  days  after  abdominal  operations  have  been  assigned  to  this  rubric, 
instead  of  to  those  covering  the  affections  for  which  operation  was  under¬ 
taken.  Personal  experience  has  demonstrated  that  the  utmost  care  is  required 
to  avoid  this  trap,  which,  owing  to  ignorance  or  intention  on  the  part  of 
surgeons,  is  so  frequently  set  for  statistical  clerks.  In  the  second  place,  as  a 
result  of  the  greatly  increased  frequency  and  impunity  with  which  abdominal 
operations  have  been  undertaken  in  this  period,  and  the  relatively  small  imme¬ 
diate  fatality,  there  has  accumulated  in  the  population  a  not  inconsiderable 
number  of  persons  with  intestinal  adhesions  or  even  progressive  chronic  peri¬ 
tonitis,  likely  to  cause  obstruction  of  the  intestines.  Therefore  it  may  well 
be  that  the  very  measures  beneficent  in  so  many  respects,  which  in  many 
instances  ward  off  death  from  some  affections  belonging  under  this  group, 
have  in  one  way  or  another  served  to  stabilize  its  officially  recorded  death-rate 
at  a  relatively  high  level. 


PART  VIII.— GENERAL  CONCLUSIONS. 


Chapter  XIX. — Deaths  from  All  Causes. 

(Tables  132  to  139,  graphs  35  to  41.) 

From  table  132  and  graph  35  it  will  be  observed  that  for  the  population  as  a 
whole  the  course  of  mortality  has  varied  widely  during  the  109  years  under 
review.  Throughout  most  of  this  period,  however,  with  few  exceptions,  as, 
for  instance,  about  1819,  1832,  1872,  and  1918 — all  years  of  unusual  epi¬ 
demics  marked  by  extraordinary  mortality — any  striking  fluctuations  in  the 
annual  rates  extended  over  considerable  periods  of  years.  Until  1895,  the 
curve  of  the  annual  rates  ran  a  wave-like  course.  Between  1812  and  1817,  the 
rate  varied  between  2,892  and  2,598.  Bising  to  3,226  in  1818  and  to  3,933, 
the  highest  ever  attained,  in  1819,  the  rate  fell  to  2,639  in  1820.  Ascending 
to  3,499  in  1822,  the  rate  declined  to  2,006  in  1824  and  to  1,824  in  1827. 
During  the  next  4  years  the  rate  ascended  gradually  to  2,459  in  1831.  Under 
the  influence  of  severe  epidemics  of  cholera  and  influenza  and  a  moderate 
visitation  of  small-pox  in  1832,  the  rate  reached  3,720.  By  1835  the  rate 
had  fallen  to  1,852,  and  in  9  of  the  succeeding  years  it  was  under  2,100; 
in  1840  it  was  as  low  as  1,690.  From  1847  the  rate  gradually  ascended  until 
1854,  when  it  reached  2,916.  From  this  level  there  was  a  gradual  though 
somewhat  irregular  decline  to  1,935  in  1865.  A  second  long  wave  beginning 
in  1866  reached  its  peak  with  a  rate  of  3,103  in  1872,  and  by  1878  had  fallen 
to  2,073.  From  1879  to  1883  the  rate  gradually  ascended  to  2,607,  and  from 
this  level  there  was  a  continuous  decline  to  2,038  in  1889.  From  this  time 
until  1907,  except  for  slight  rises  in  1890-1892  and  in  1895,  the  rate  fluctu¬ 
ated  between  2,100  and  1,923.  During  the  following  10  years  the  rate  was 
always  below  1,900,  and  in  one  year,  1915,  below  1,700.  It  rose  to  2,596  in 
1918,  to  fall  to  the  lowest  recorded  levels,  1,585  and  1,548  in  1919  and  1920, 
respectively.  It  will  be  observed  that,  while  in  several  years  in  the  third, 
fourth,  fifth,  and  seventh  decades  the  rate  fell  below  2,000,  it  was  not  until 
the  twentieth  century  that  rates  so  low  were  common,  nor  until  after  1908 
were  they  of  constant  (except  in  1918)  occurrence.  It  was  only  after  1895 
that  these  marked  waves  of  increased  mortality  ceased  to  appear. 

In  considering  the  difference  in  the  course  of  mortality  in  the  white  and 
negro  races,  and  in  comparing  the  curves  for  these  with  that  for  the  total 
population,  it  must  be  borne  in  mind  that  until  1857  the  rates  for  whites  and 
negroes  separately  are  based  on  figures  which  include  still-births.  This  is  due 
to  the  fact  that  until  this  date  in  the  tables  of  mortality  the  white  and  negro 
still-births  were  not  tabulated  separately.  In  consequence  these  rates  are  for 
this  period  somewhat  higher  than  would  be  the  true  rates  calculated  on  the 
usual  basis,  and  the  difference  between  the  white  rate  and  the  total  rate  is  less 
marked  and  between  the  total  rate  and  the  negro  rate  is  more  pronounced 
than  would  be  the  case  but  for  this  fault  in  the  original  data.  As  throughout 
33  507 


Table  132. — Deaths  from  all  causes ,  exclusive  of  still-births*  per  100,000  living  inhabitants,  from  1812  to  1920,  inclusive. 

D  =  death.  R  =  rate. 


508  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


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Number  of  deaths  and  the  rates  of  death  for  white  and  colored  include  still-births  from  1818  to  1856,  inclusive. 


Table  132. — Deaths  from  all  causes,  exclusive  of  still-births. — Continued. 

D  =  death.  R  =  rate. 


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GENERAL  CONCLUSIONS 


511 


the  whole  period  the  whites  have  constituted  a  so  overwhelmingly  large  pro¬ 
portion  of  the  population,  their  rate  has  been  the  determining  factor  in  the 
rate  for  the  whole  population.  It  is  not  surprising,  therefore,  that  before  1857 
the  white  rate  as  calculated  approaches  or  even  surpasses  the  level  of  the  total 
rate.  As  the  chief  interest  in  the  comparison  lies  in  the  differences  between 
the  wdiite  and  the  negro  rates,  the  inclusion  of  still-births  in  the  earlier  period 
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exception  of  a  few  years  (1821,  1853,  1854,  1862,  1863),  the  negro  rate  was 
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difference  in  favor  of  the  whites  is  striking.  The  near  approach  of  the  two 


Graph  35  (from  table  132).  Animal  crude  mortality -rates  from  all  causes 
in  the  whole  population,  in  whites,  and  in  negroes,  from  1812  to  1920,  in¬ 
clusive. 

rates  in  the  sixth  and  seventh  decades  of  the  nineteenth  century  occurred  in 
a  period  of  very  marked  decline  in  the  proportion  of  negroes  to  whites  in  the 
population.  To  a  certain  degree,  at  least,  the  decline  in  the  rate  for  negroes 
in  this  period  was  also  associated  with  the  higher  proportion  of  cases  of  small¬ 
pox  and  typhus  fever  in  this  race  hospitalized  without  the  city  limits.  With 
the  exceptions  above  noted,  there  is  a  very  definite  correspondence  between  the 
course  of  the  curves  for  the  two  rates,  which  rise  and  fall  together,  and  but 
for  the  difference  in  their  levels,  the  three  curves  follow  much  the  same  courses. 

The  course  of  the  rate  for  whites  followed  so  closely  that  of  the  rate  for 
the  whole  population  until  1875  that  it  is  unnecessary  to  trace  it  separately. 
From  1885,  with  the  exception  of  1890  to  1892,  inclusive,  and  1918,  the  white 
rate  never  exceeded  2,000,  and,  after  1905,  in  only  one  year  (1918)  did  it  rise 


512  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

above  1,800.  It  dropped  below  1,500  for  the  first  time  in  1915,  and  in  1920  it 
fell  to  1,404.  In  1918,  the  year  of  the  great  influenza  epidemic,  this  rate 
attained  2,374,  a  level  relatively  low  when  compared  with  certain  earlier  years. 
Particularly  high  rates  in  the  earlier  period  were  3,043  in  1818,  4,034  in  1819 
(yellow  fever) ;  3,408,  3,552,  and  2,832  in  1821,  1822,  and  1823 ;  3,032  in  1832  ; 
3,015,  2,909,  3,130,  2,856,  and  2,904  in  1852,  1853,  1854,  1855,  and  1856, 
respectively,  and  2,970  in  1872.  These  very  high  rates  were  associated  with 
years  of  severe  visitations  of  yellow  fever,  cholera,  typhus  fever,  or  small¬ 
pox.  The  6-year  period  between  1839  and  1844,  when  the  rate  never  exceeded 
2,000,  was  peculiarly  healthy. 

Between  1817  and  1852  the  rate  in  negroes  fell  below  3,000  in  only  8 
years.  The  lowest  rate  recorded  in  this  period  was  2,449  in  1840.  Extra¬ 
ordinarily  high  rates  were  4,573,  4,409,  4,180,  and  4,621  in  1818,  1819,  1822, 
and  1823,  respectively;  6,573  in  1832,  3,829  in  1872,  3,775  in  1877,  3,945, 
3,772,  and  4,078  in  1881  to  1883,  and  3,757  in  1918.  Rates  uniformly 
below  3,000  occurred  between  1857  and  1869,  and  in  this  period  rates  under 
2,400  were  recorded  in  5  years.  Between  1870  and  1907,  the  rates  fell  below 
3,000  in  only  two  years.  After  the  latter  date  the  rate  rose  above  3,000  in 
only  two  years  (1917  and  1918).  From  1885  to  1907  the  rates  ran  on  a  fairly 
even  level  and  not  far  from  3,000.  The  decline  to  2,440  and  2,370  for  1919 
and  1920,  respectively,  while  striking,  did  not  bring  the  rate  below  levels 
previously  recorded. 

Turning  now  to  rates  averaged  for  5-year  periods  (table  133,  graph  36), 
the  course  of  mortality  from  all  causes  can  be  followed  with  greater  clearness. 
For  the  whole  population  the  rates  rose  from  2,758  for  the  period  1812-1815 
to  3,019  for  the  quinquennium  ending  in  1820.  For  the  next  5  years  the  rate 
fell  to  the  level  of  the  first  period,  and  for  1826-1830  it  declined  to  2,149. 
Between  1831  and  1835  the  rate  rebounded  to  '2,609,  only  to  fall  again  to 
2,034  for  1836-1840  and  to  the  extremely  low  level  of  1,892  for  1841-1845, 
a  level  not  to  be  bettered  until  1911-1915.  The  wave  extending  over  the  20 
years  between  1846  and  1865  reached  its  peak  with  a  rate  of  2,728  for  the 
5-year  period  1851-1855.  Descending  to  2,241  for  the  quinquennium  1861- 
1865,  the  rate  gradually  ascended  again,  and  for  the  5  years  ending  in  1875 
was  2,625.  Falling  slightly  between  1876  and  1880  and  rising  somewhat  for 
the  next  5-year  period,  the  rate  declined  to  2,170  for  the  5  years  ending  in 
1890.  After  remaining  practically  stationary  for  the  succeeding  quinquennium, 
from  1896  the  averaged  rate  fell  steadily  to  1,749  during  the  quinquennium 
1911-1915.  For  1916-1920  the  rate  was  1,870. 

The  curve  of  the  white  rate  ran  nearly  parallel  with  that  for  the  total  rate 
until  1875.  After  this  date  it  dropped  substantially  and  almost  unbrokenly 
until  1915.  For  the  period  1841-1845,  the  rate  for  this  category  was  only 
1,870.  The  highest  levels  reached  were  3,209  in  1816-1820,  2,766  in  1821- 
1826,  and  2,899  in  1851-1855.  The  rate  had  declined  to  1,988  by  1886-1890. 
The  low  point  was  reached  in  1911-1915  with  a  rate  of  1,568. 

The  rate  for  negroes,  like  the  total  rate  and  the  white  rate,  fell  continuously 
from  1816  to  1830,  and  also  like  these  but  for  the  ascent  between  1831-1840 
it  would  have  continued  at  a  comparatively  low  level  until  1845.  The  peak 
periods  1816-1820  and  1831-1835  were  characterized  by  the  excessively  high 
rates  of  4,220  and  4,124,  respectively.  From  a  level  of  2,861  for  the  quin- 


GENERAL  CONCLUSIONS 


513 


Table  133j — Average  rate  of  death,  per  100,000  living  inhabitants,  by  5-year  periods, 
from  all  causes  excluding  still-births,  total  causes  unknown,  and  still-births,  from 
1812  to  1920,  inclusive. 


Periods. 

Deaths  from  all 
causes,  exclud¬ 
ing  still-births. 

Total  causes 
unknown. 

Still-births. 

Periods. 

Deaths  from  all 
causes,  exclud¬ 
ing  still-births. 

Total  causes 

unknown. 

Still-births. 

i 

Total. 

White.* 

Colored.* 

Total. 

White.* 

Colored.* 

1812-15 _ 

2758 

•  •  •  • 

•  •  •  • 

145 

219 

1866-70  _ 

2363 

2290 

2756 

399 

163 

1816-20 _ 

3019 

3209 

4220 

143 

186 

1871-75  _ 

2625 

2482 

3401 

248 

159 

1821-25  .... 

2756 

2766 

3472 

278 

162 

1876-80  _ 

2328 

2116 

3491 

19 

187 

1826-30  _ 

2149 

2073 

3082 

457 

127 

1881-85  _ 

2425 

2199 

3668 

13 

190 

1831-35  _ 

2609 

2430 

4124 

473 

143 

1886-90  _ 

2170 

1988 

3182 

5 

180 

1836-40  _ 

2034 

1986 

3182 

466 

169 

1891-95  _ 

2191 

2000 

3253 

5 

166 

1841-45  .... 

1892 

1870 

2861 

410 

149 

1896-1900  .. 

2048 

1846 

3168 

7 

143 

1846-50  _ 

2401 

2484 

3400 

437 

236 

1901-05  _ 

1987 

1762 

3222 

21 

136 

1851-55  _ 

2728 

2899 

3088 

379 

201 

1906-10  .... 

1912 

1703 

3006 

54 

145 

1856-60  _ 

2488 

2507 

2675 

409 

199 

1911-15 _ 

1749 

1568 

2713 

13 

151 

1861-65  _ 

2241 

2226 

2322 

390 

138 

1916-20 _ 

1870 

1682 

2893 

1 

196 

*  These  averages  for  white  and  colored  include  still-births  until  1857. 


Graph  36  (from  table  133).  Crude  mortality-rates  from  all  causes  in  the 
whole  population,  in  whites,  and  in  negroes,  averaged  by  5-year  periods, 
from  1812  to  1920,  inclusive. 


514  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


quennium  1841-1846,  the  rate  for  negroes  rose  comparatively  slightly  during 
the  succeeding  5  years  and,  in  contrast  to  the  rate  for  whites,  instead  of  con¬ 
tinuing  to  rise  between  1851-1855  and  attaining  a  higher  peak,  it  entered 
upon  a  long  decline  covering  the  15  years  between  1851  and  1865,  and  for  the 
period  1861-1865  stood  at  2,322.  These  15  years  were  a  period  of  stagnation 
in  negro  immigration,  during  which  the  negro  population  declined  actually 
and  relatively.  Again,  after  1865  the  course  of  the  rate  for  negroes  followed 
a  course  rather  different  from  that  pursued  by  the  rate  for  whites.  While 
between  1866  and  1875  the  rate  for  whites  showed  only  a  slight  increase,  that 
for  negroes  rose  to  2,756  for  1866-1870,  3,401  for  1871-1875,  3,491  for 


Table  134. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from  all  causes,  by 

color  and  sex,  from  1878  to  1920,  inclusive. 

D  =  death.  R  =  rate. 


Year. 

White. 

Colored. 

Year. 

White. 

Colored. 

Male. 

Fem. 

Male. 

1 

Fem. 

Male. 

Fem. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

1878 

2556 

1924 

2603 

1834 

716 

3376 

858 

2975 

1900 

4179 

2012 

3914 

1767 

1251 

3606 

1356 

3149 

1879 

2970 

2190 

2913 

2010 

851 

3921 

884 

3011 

1901 

4095 

1943 

3761 

1678 

1336 

3788 

1287 

2947 

1880 

3180 

2297 

2990 

2020 

888 

3998 

985 

3295 

1902 

4072 

1905 

3661 

1614 

1274 

3553 

1246 

2814 

1881 

3402 

2407 

3317 

2195 

1008 

4436 

1089 

3579 

1903 

4027 

1858 

3632 

1583 

1214 

3331 

1268 

2825 

1882 

3607 

2501 

3273 

2122 

1007 

4332 

1038 

3352 

1904 

4271 

1944 

3825 

1649 

1383 

3734 

1339 

2944 

1883 

3659 

2486 

3466 

2202 

1078 

4535 

1177 

3734 

1905 

4202 

1888 

3737 

1594 

1363 

3622 

1393 

3022 

1884 

3340 

2225 

3058 

1905 

906 

3727 

989 

3083 

1906 

4308 

1911 

3725 

1573 

1355 

3544 

1365 

2923 

1885 

3211 

2097 

3113 

1901 

878 

3532 

951 

2914 

1907 

4429 

1940 

3949 

1651 

1422 

3663 

1390 

2939 

1886 

3283 

2103 

3194 

1912 

870 

3424 

992 

2988 

1908 

4144 

1793 

3730 

1544 

1317 

3341 

1244 

2598 

1887 

3250 

2042 

3130 

1838 

942 

3627 

1050 

3109 

1909 

4073 

1742 

3718 

1525 

1321 

3302 

1264 

2607 

1888 

3578 

2102 

3316 

1786 

988 

3540 

1054 

2944 

1910 

4236 

1791 

3910 

1589 

1352 

3330 

1255 

2557 

1889 

3436 

1982 

3383 

1791 

913 

3209 

971 

2668 

1911 

4141 

1731 

3618 

1458 

1351 

3279 

1294 

2606 

1890 

4112 

2329 

3914 

2038 

1047 

3610 

1125 

3041 

1912 

4190 

1732 

3690 

1474 

1362 

3259 

1199 

2386 

1891 

4055 

2256 

3783 

1939 

1065 

3604 

1170 

3112 

1913 

4043 

1653 

3807 

1509 

1201 

2834 

1117 

2197 

1892 

4301 

2352 

4060 

2048 

1105 

3670 

1116 

2921 

1914 

4219 

1708 

3695 

1453 

1368 

3183 

1269 

2468 

1893 

3741 

2011 

3629 

1803 

1105 

3603 

1079 

2780 

1915 

3962 

1587 

3563 

1390 

1302 

2989 

1175 

2260 

1894 

3731 

1972 

3511 

1719 

1087 

3480 

1157 

2939 

1916 

4256 

1688 

3727 

1444 

1400 

3171 

1336 

2542 

1895 

4069 

2116 

3815 

1841 

1213 

3814 

1204 

3008 

1917 

4513 

1773 

3849 

1481 

1639 

3663 

1363 

2566 

1896 

3956 

2024 

3656 

1739 

1140 

3521 

1167 

2872 

1918 

6632 

2581 

5680 

2170 

1873 

4132 

1847 

3441 

1897 

3760 

1894 

3403 

1597 

1091 

3311 

1075 

2607 

1919 

4637 

1509 

4253 

1373 

1328 

2774 

1216 

2156 

1898 

4102 

2034 

3806 

1763 

1218 

3633 

1259 

3009 

1920 

4428 

1436 

4351 

1374 

1263 

2371 

1314 

2368 

1899 

3982 

1945 

3782 

1728 

1187 

3480 

1201 

2829 

1876-1880,  and  3,668  for  1881-1885.  In  the  meantime,  on  its  much  lower 
level  the  rate  for  whites  had  been  declining  since  1875.  For  the  20  years 
between  1886  and  1905,  the  rate  for  negroes  held  nearly  constant  around 
3,200,  while  the  rate  for  whites  was  undergoing  a  considerable  decline.  For 
the  quinquennium  1911-1915  the  rate  for  negroes  fell  to  2,713,  to  rise  to 
2,893  for  that  ending  in  1920.  The  period  under  consideration  ends,  then, 
with  a  rate  for  negroes  higher  than  between  1841-1845,  and  1856-1870. 

Data  for  the  study  of  the  influence  of  sex  in  respect  of  race  upon  the  mor¬ 
tality  from  all  causes  are  available  since  1878,  and  are  represented  in  tables 
134  and  135  and  graph  37.  During  this  period  there  has  been  a  striking 
difference  in  favor  of  females.  It  will  be  observed  that  the  rates  for  females 
have  been  uniformly  lower  than  those  for  males,  and  it  is  notable  that,  with 


GENERAL  CONCLUSIONS 


515 


the  annual  rates  with  a  few  exceptions  and  with  the  rates  as  averaged  for 
5-year  periods  without  exception,  the  mortality  for  the  two  sexes  in  both 
races  rose  and  fell  together.  Among  whites,  the  difference  between  the  rates 


Table  135. — Average  rate  of  death,  per  100,000  living  inhabi¬ 
tants,  by  5-year  periods,  from  all  caiLses,  by  color  and 
sex,  from  1878  to  1920,  inclusive. 


Period. 

White. 

Colored. 

Male. 

Fem. 

Male. 

Fem. 

1878-80  . 

2137 

1955 

3765 

3093 

1881-85  . 

2343 

2065 

4112 

3332 

1886-90  . 

2112 

1873 

3482 

2950 

1891-95  . 

2141 

1870 

3634 

2952 

1896-1900  . 

1982 

1719 

3510 

2893 

1901-05  . 

1908 

1624 

3606 

2910 

1906-10  . 

1835 

1576 

3436 

2725 

1911-15  . 

1722 

1457 

3109 

2383 

1916-20  . 

1797 

1568 

3222 

2615 

Graph  37  (from  table  134).  Annual  mortality-rates  from  all  causes,  by  color 

and  sex,  from  1878  to  1920,  inclusive. 


for  males  and  females  was  less  marked  before  1885  and  after  1918  than  in 
the  intermediate  period.  Throughout  the  latter,  especially  when  judged  by 
the  averaged  rates,  the  difference  between  the  level  of  the  two  rates  is  singu¬ 
larly  uniform.  Among  negroes,  except  in  a  few  years,  notably  1878  and  1920, 


516  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

when  the  rates  for  males  and  females  approximated  each  other  closely  and 
in  a  few  other  years  when  they  deviated  somewhat  more  sharply  than  usual, 
the  difference  in  mortality  for  the  two  sexes  was  very  uniform. 

Between  1814  and  1920,  inclusive,  and  in  unbroken  series,  the  distribution 
of  deaths  according  to  the  age  of  the  decedents  is  recorded  annually  in  the 
official  records  of  the  health  department  under  the  same  age-groupings,  0  to 
1,  between  1  and  2,  between  2  and  4,  under  5,  and  between  5  and  9  years,  and 
thereafter  by  decades  of  life.  Deaths  by  age,  sex,  and  color  are  recorded  for 
1910  and  1920.  On  account  of  the  questionable  accuracy  of  the  estimated 
figures  for  these  age-groups  of  the  population  in  certain  years  (see  chapter 
on  population),  the  enormous  amount  of  work  involved  in  the  necessary  calcu¬ 
lations,  and  the  great  expense  of  printing  such  voluminous  tables,  it  is  imprac¬ 
ticable  to  present  here  mortality-rates  specific  for  age  for  the  inter-censal 
years.  So  important  in  some  ways  and  so  unique  are  these  data  that  after 
studying  rates  specific  for  these  age-groupings  for  the  census  years  1830  to 
1920,  they  will  be  considered  in  their  proportional  relation  to  the  whole  num¬ 
ber  of  annual  deaths  and  such  correspondences  in  the  trends  of  these  figures 
and  the  specific  rates  as  may  appear  will  be  pointed  out. 

Bates  specific  for  age  for  the  whole  population  in  the  several  census  years 
1830  to  1920,  inclusive,  are  given  in  table  136  and  graph  38.  As  the  popula¬ 
tion  figures  for  certain  of  the  age-groups  in  1830  and  1840,  1870,  1880,  and 
1890  were  estimated  (see  table  10),  the  resulting  rates  must  be  regarded  as 
only  approximately  correct.  In  regard  to  the  first  year  of  life,  it  will  be 
observed  that  the  rate  rose  somewhat  gradually  from  16,697  in  1850  to  28,640 
in  1890,  and  then  fell  for  each  successive  decennium  to  13,197  in  1920.  In 
the  age-group  0  to  4  years  the  rate,  after  falling  from  7,232  in  1830  to  5,891 
in  1840,  rose  to  a  peak  of  10,631  in  1870,  and  thereafter  fell  continuously 
to  4,107  in  1920.  In  order  of  sequence,  the  highest  rates  occurred  in  1870, 
1880,  1890,  1850,  1860,  and  1830,  and  the  lowest  in  1840,  1910,  and  1920. 
In  the  age-period  5  to  9  years  the  rate,  after  falling  from  1,164  in  1830  to  836 
in  1840,  and  reacting  to  1,311  in  1850,  fell  to  911  in  1860,  and  then  rising 
to  its  peak  of  1,502  in  1880,  by  1920  had  declined  to  313,  a  difference  in  the 
extremes  even  more  striking  than  in  the  other  two  categories.  In  these  age- 
groups,  then,  the  rates  fell  significantly  between  1830  and  1840,  rose  markedly 
between  1840  and  1870  or  1880,  and  declined  in  even  greater  degree  between 
these  dates  and  1920.  Consequently  in  the  first  decade  of  life,  a  like  dispro¬ 
portion  existed  between  the  rates  for  1840  and  1870  and  between  those  of 
1880  and  1920. 

In  the  second  decade  of  life,  when,  for  each  particular  census  year  without 
exception  the  mortality  was  lightest,  the  rates  stood  in  order  of  their  high 
levels,  1850,  1870,  1860,  1830,  and  1880,  and  their  low  levels,  1890,  1840, 
1900,  1910,  and  1920.  Between  1850  and  1880,  the  recession  was  compara¬ 
tively  slight,  while  that  between  1880  and  1920  was  marked,  and  the  declines  for 
each  succeeding  decennium  were  in  ever-increasing  ratio.  For  the  third  decade 
of  life  the  mortality  was  highest  in  1850,  1830,  1870,  1880,  and  1890,  and 
lowest  in  1840,  1900,  1910,  and  1920.  For  the  fourth  decade  the  sequence  of 
high  rates  according  to  years  was  1830,  1850,  1840,  1870,  1890,  1880,  1860 
and  of  the  low  rates  1900,  1910,  and  1920.  Whatever  the  changes  among  the 
others  may  have  been,  up  to  this  age-group,  1900,  1910,  and  1920,  and, 


GENERAL  CONCLUSIONS 


517 


Table  136. — Number  of  deaths  and  rate  of  death,  per  100,000  living  inhabitants,  from  all  causes, 
according  to  age  for  the  census  years  1830,  18Jfi,  1850,  1860,  1870,  1880,  1890,  and  1900,  and 
according  to  age,  sex,  and  color  for  1910  and  1920. 


D  =  death.  R  =  rate. 


Age-groups. 

1830 

1840 

1850 

1860 

1870 

1880 

1890 

1900 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

Under  1  year . 

Between  1  and  2  years  . 

2  to  4  years . 

0  to  4  years . 

5  to  9  years . 

0  to  9  years . 

10  to  19  years . 

20  to  29  years . 

30  to  39  years . 

40  to  49  years . 

50  to  59  years . 

60  to  69  vears . 

70  to  79  years . 

80  years  and  over . 

Total . 

406 

184 

232 

822 

110 

933 

123 

193 

202 

214 

126 

85 

57 

42 

•  •  •  • 

7232 

1164 

4478 

641 

1129 

1855 

3411 

3591 

4874 

6840 

10660 

532 

182 

183 

897 

93 

990 

123 

205 

226 

166 

126 

82 

76 

51 

•  •  •  « 

•  •  •  • 

5891 

806 

3700 

555 

909 

1517 

2085 

2838 

3600 

8889 

11778 

1023 
544  1 
488  < 
2055 
263 
2318 
247 
399 
381 
278 
220 
157 
134 

86 

16697 

5600 

8369 

1311 

5195 

675 

1161 

1551 

1916 

2715 

3813 

8156 

13014 

1227 
616  | 
539  ( 
2382 
234 
2616 
282 
395 
418 
323 
243 
260 
210 
119 

18813 

4832 

7830 

911 

4662 

643 

975 

1311 

1562 

2155 

4783 

10314 

19070 

2098 
855  1 
722  r 
3675 
301 
3976 
360 
574 
562 
500 
443 
385 
278 
184 

27806 

5836 

10631 

982 

6096 

662 

1099 

1428 

1837 

2696 

4616 

8533 

20109 

2329 
701  | 
572  | 
3602 
541 
4143 
396 
663 
599 
529 
529 
514 
426 
244 

27227 

4273 

9394 

1502 

5571 

694 

998 

1249 

1498 

2280 

4203 

8667 

18813 

2740 
894  | 
483  f 
4117 
441 
4558 
479 
843 
834 
784 
804 
1085 
498 
313 

28640 

3771 

8934 

971 

4981 

562 

960 

1276 

1676 

2645 

6440 

7403 

10493 

2627 

525 

543 

3695 

325 

4020 

483 

916 

947 

952 

959 

1084 

860 

479 

24225 

5599 

1792 

7314 

636 

3956 

490 

904 

1187 

1639 

2648 

5231 

9574 

22094 

1974 

2449 

2045 

1999 

4210 

2490 

4866 

2291 

7262 

2716 

8043 

2420 

10198 

2352 

10700 

2108 

1910 


White. 

Colored. 

Age-groups. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

Under  1  year . 

2148 

20979 

1566 

17613 

856 

19069 

710 

16129 

582 

43175 

356 

51971 

226 

34087 

Between  1  and  2  years. 

399 

4151 

304 

3583 

161 

3672 

143 

3487 

95 

8429 

52 

9336 

43 

7544 

2  to  4  years . 

344 

1070 

240 

858 

122 

868 

118 

848 

104 

2503 

54 

2684 

50 

2333 

0  to  4  years . 

2891 

5561 

2110 

4652 

1139 

4966 

971 

4331 

781 

11780 

462 

14198 

319 

9449 

5  to  9  years . 

188 

379 

146 

338 

73 

337 

73 

339 

42 

654 

15 

490 

27 

804 

0  to  9  years . 

3079 

3030 

2256 

2548 

1212 

2717 

1044 

2376 

823 

6307 

477 

7555 

346 

5133 

10  to  19  years . 

451 

439 

301 

338 

146 

341 

155 

336 

150 

1089 

62 

1060 

88 

1111 

20  to  29  years . 

883 

781 

570 

617 

289 

650 

281 

586 

313 

1518 

156 

1725 

157 

1356 

30  to  39  years . 

1010 

1131 

686 

934 

393 

1105 

293 

773 

324 

2050 

174 

2275 

150 

1839 

40  to  49  years . 

1094 

1595 

760 

1329 

420 

1524 

340 

1147 

334 

2931 

170 

3006 

164 

2857 

50  to  59  years . 

1256 

2784 

977 

2502 

553 

2929 

424 

2102 

279 

4602 

145 

4899 

134 

4318 

60  to  69  years . 

1352 

5451 

1138 

5192 

628 

6354 

510 

4238 

214 

7410 

100 

7576 

114 

7270 

70  to  79  years . 

1067 

10208 

976 

10320 

427 

10843 

549 

9947 

91 

9137 

45 

11166 

46 

7757 

80  years  and  over . 

561 

21003 

4S2 

20295 

168 

19580 

314 

20699 

79 

26689 

23 

24731 

56 

27586 

Total . 

10753 

1925 

8146 

1721 

4236 

1851 

3910 

1599 

2607 

3064 

1352 

3433 

1255 

2745 

1920 


Age-groups. 

Total. 

White. 

Colored. 

Total. 

Male. 

Fem. 

Total. 

Male. 

Fem. 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

D 

R 

Under  1  year . 

Between  1  and  2  years.. 

2  to  4  years . 

0  to  4  3'ears . 

5  to  9  years . 

0  to  9  years . 

10  to  19  years . 

20  to  29  years . 

30  to  39  years . 

40  to  49  years . 

50  to  59  years . 

60  to  69  vears . 

70  to  79  vears . 

80  years  and  over . 

Total . 

1960 
379  1 
304  f 
2643 
202 
2845 
383 
959 
1030 
1174 
1448 
1569 
1325 
623 

13197 

1253 

4107 

313 

2126 

310 

662 

842 

1271 

2314 

4357 

9192 

17902 

1490 
270  ) 
227  i 
1987 
161 
2148 
266 
642 
693 
809 
1110 
1321 
1216 
574 

11565 

1033 

3258 

285 

1830 

247 

539 

689 

1054 

2029 

4059 

9312 

18362 

826 
130  1 
119  f 
1075 

94 

1169 

119 

295 

368 

416 

601 

704 

551 

205 

12515 

1031 

3497 

329 

1970 

225 

502 

730 

1089 

2252 

4600 

9845 

18255 

664 
140  | 
108  f 
912 

67 

979 

147 

347 

325 

393 

509 

617 

665 
369 

10567 

1035 

3016 

241 

1686 

267 

576 

648 

1019 

1816 

3580 

8913 

18422 

470 
109  | 
77  ( 
656 

41 

697 

117 

317 

337 
365 

338 
248 
109 

49 

23882 

29C3 

7833 

508 

4239 

734 

1227 

1544 

2343 

4301 

7157 

8038 

13842 

258 
561 
37  j 
351 

23 

374 

39 

147 

168 

182 

161 

115 

57 

20 

26959 

2987 

8624 

596 

4716 

552 

1206 

1520 

2197 

3793 

6713 

9421 

14925 

212 

53  I 
40  j 
305 

18 

323 

78 

170 

169 

183 

177 

133 

52 

29 

20969 

2823 

7085 
*  428 
3794 
878 
1246 
1570 
2510 
4899 
7591 
6924 
13182 

11356 

1548 

8780 

1405 

4429 

1436 

4351 

1373 

2577 

2371 

1263 

2372 

1314 

2369 

518  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

through  the  first  three  decades  of  life,  1840,  held  steadily  the  same  relative 
positions  as  years  of  low  rates  and  invariably  registered  the  lowest  mortality. 
With  the  fifth  decade  of  life  there  began  a  notable  rearrangement,  through 
which,  finally,  with  advancing  age,  though  in  rather  irregular  progression, 
relative  to  each  other  the  rates  in  the  earlier  census  years  fell  and  those  in  the 
latter  rose  to  high  levels.  In  consequence,  it  appears  as  a  general  law  that 
when  the  force  of  mortality  was  strongest  in  the  first  four  decades  it  generally 
weakened  during  the  remainder  of  life,  and,  conversely,  that  when  this  force 
was  relatively  less  vigorous  in  early  life,  it  gained  in  strength  proportionately 
after  middle  life. 


Graph  38  (from  table  136).  Mortality-rates  from  all  causes,  specific  for 
age  in  the  whole  population,  for  the  census  years  1830,  1850,  1900  and 
1920. 

From  table  136  and  graph  38  it  is  very  evident  that  the  rate  for  the  age- 
group  below  the  tenth  year,  which  during  the  whole  period  until  after  1910 
carried  the  highest  mortality  of  any  decade  of  life  under  the  sixth,  rose  on  the 
whole  between  1830  and  1870  and  thereafter  declined  continuously.  For  the 
second  half  of  this  age-group,  namely,  from  5  to  9  years,  the  mortality-rate, 
after  fluctuating  rather  widely  between  1830  and  1860  and  during  these 
30  years  following  closely  that  for  the  third  decade  of  life,  rose  abruptly  from 
1860  to  1880,  when  it  surpassed  that  for  the  fifth  decade.  After  1880  it  fell 
sharply,  and  by  1920  it  was  but  little  higher  than  that  for  the  second  decade 
of  life.  The  rate  for  the  first  demi-decade,  0  to  4  years,  higher  between  1870 
and  1890  than  that  for  the  eighth  decade  of  life,  declined  markedly  after  1870. 
For  the  first  year  of  life  the  rate  rose  slightly  between  1850  and  1860,  sharply 
between  1860  and  1870,  reached  its  peak  in  1890  and  fell  gradually  until 


GENERAL  CONCLUSIONS 


519 


1910  and  conspicuously  between  1910  and  1920.  Except  for  the  slight  drop 
between  1830  and  1840,  the  mortality-rates  for  the  second  and  third  decades 
showed  but  little  change  from  1830  to  1890,  but  between  the  latter  date  and 
1920  the  fall  was  considerable  in  each  case.  In  the  fourth  decade  the  death- 
rate  fell  notably  from  1830  to  1860,  but  for  the  next  30  years  it  ran  an  almost 
level  course;  with  but  a  slight  drop  between  1890  and  1910,  in  the  last  10 
years  there  was  a  conspicuous  decline.  In  the  fifth  decade  the  rate  declined 
considerably,  and  but  for  a  reaction  in  1870,  steadily,  from  1830  to  1880; 
rising  in  1890  to  a  level  higher  than  in  1860,  and  remaining  almost  stationary 
for  the  next  30  years,  the  rate  fell  to  its  lowest  point  in  1920.  For  the  sixth 
decade  the  mortality-rate  fell  in  considerable  degree  from  1830  to  1860,  but 
from  the  latter  date,  except  for  a  decline  in  1870,  the  trend  was  continuously 
upwards  during  the  succeeding  50  years,  and  by  1910  the  rate  was  higher 
than  in  1850.  The  slight  decline  between  1910  and  1920  failed  to  lower  the 
rate  to  the  level  of  1860.  The  course  of  the  rate  of  the  seventh  decade  was 
characterized  by  great  instability.  Falling  markedly  from  1830  to  1840  and 
then  rising  by  1860  to  near  the  level  of  1830,  it  again  declined  until  1880. 
Reaching  a  high  peak  in  1890,  by  1920  it  had  fallen  to  a  level  but  slightly 
higher  than  that  obtaining  in  1880.  For  the  age-groups  over  70  years  the 
mortality-rates,  while  pursuing  a  somewhat  irregular  course,  w’ere  considerably 
higher  in  1920  than  in  1830.  It  is  noteworthy  that  between  1910  and  1920 
every  age-group  and  between  1830  and  1840  all,  but  the  two  highest,  showed 
distinct  declines. 

On  the  whole,  during  the  90  years  between  1830  and  1920,  the  several  age- 
groups  above  the  fiftieth  year  exhibited  no  fall  in  mortality.  In  extreme  old 
age  the  trend  of  mortality  was  distinctly  upward.  In  all  of  the  age-groups 
below  the  fiftieth  year  decided  declines  occurred.  Among  the  latter,  except 
for  age-group  40  to  49  years,  all  substantial  recessions  in  mortality  have  taken 
place  since  1870.  This  phenomenon  is  well  illustrated  by  a  comparison  of  the 
courses  of  the  rates  in  the  various  census  years  for  the  population  above  and 
below  the  fortieth  year  of  life  with  those  for  the  whole  population.  This  is 
done  in  table  137.  Here  the  determining  influence  of  the  decline  in  mortality 
under  the  fortieth  year  upon  that  for  all  ages  since  1870  is  brought  out  very 
clearly.  The  failure  of  any  decline  in  the  force  of  mortality  in  the  remainder 
of  the  population  is  equally  evident.  As  in  the  natural  order  all  must  die, 
no  considerable  decrease  in  the  rate  of  death  for  the  age-groups  above  the 
fortieth  year  can  be  predicated ;  but  the  point  here  made  clear  is  that  between 
1830  and  1920  for  this  age-group  as  a  whole  there  was  no  extension,  but  rather 
a  decline  in  the  duration  of  life,  and  for  the  age-group  below  the  fortieth  year, 
while  no  decline  in  the  death-rate  occurred  between  1830  and  1870,  since  the 
latter  date  it  has  fallen  by  nearly  60  per  cent. 

Data  for  the  calculation  of  rates  specific  for  age,  color,  and  sex  are  available 
for  1910  and  1920  (table  136).  In  1910,  when  among  both  whites  and  negroes 
the  rates  for  males  was  considerably  higher  than  for  females,  the  mortality 
was  greater  among  whites  for  males  than  for  females  in  all  the  age-groups 
except  5  to  9  and  80  years  and  over,  and  among  negroes  in  males  for  every 
age-group  except  5  to  9,  10  to  19,  and  80  years  and  over.  This  excess  of  male 
mortality  was  particularly  marked  in  the  whites  in  the  first,  fifth,  sixth,  and 
seventh,  and  in  negroes  in  the  first,  third,  and  eighth  decades  of  life.  In  1920, 


520  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


when  the  differences  between  the  rates  for  all  ages  in  the  two  sexes  of  both 
races  was  comparatively  slight,  the  rates  were  higher  in  males  than  in  females 
in  all  the  age-groups  among  whites,  except  in  the  third  decade  and  80  years 
and  over,  and  among  negroes  in  females  than  in  males  except  the  first  and 
eighth  decades  and  80  years  and  over.  In  both  years  mortality  was  higher  in 
negroes  than  in  whites  in  all  age-groups  except  in  the  eighth  decade.  This 
difference  in  favor  of  the  white  was  greatest  below  the  fiftieth  year  of  life, 
and  in  the  earlier  age-groups  amounted  to  from  100  to  150  per  cent.  In  every 


Table  137. — Number  of  deaths  and  rate  of  death,  per  100,000 
living  inhabitants,  specific  for  the  total  number,  those  under 
40  years  of  age,  and  those  40  years  of  age  and  over,  for  the 
decennia  1830  to  1920,  inclusive .* 


Decennia. 

Total. 

Under  40  years. 

40  years  and 
over. 

D 

R 

D 

R 

D 

R 

1830  . 

1967 

2440 

1454 

2139 

513 

2265 

1840  . 

2184 

2135 

1675 

1940 

509 

3188 

1850  . 

4181 

2473 

3264 

2329 

917 

3167 

1860  . 

4776 

2248 

3669 

2129 

1107 

2764 

1870  . 

6970 

2607 

5281 

2501 

1689 

3008 

1880  . 

8159 

2455 

5904 

2312 

2255 

2930 

1890  . 

9658 

2228 

6235 

1890 

3423 

3300 

1900  . 

10443 

2058 

6041 

1584 

4402 

3489 

1910  . 

10511 

1884 

5363 

1320 

5148 

3395 

1920  . 

11395 

1553 

5305 

1011 

6090 

2917 

*  The  number  of  deaths  for  each  decennium  is  a  3-year  average 
of  that  obtaining  in  the  decennial  year  and  in  those  years  im¬ 
mediately  preceding  and  following,  except  in  1920  when  the 
average  is  for  1919  and  1920  only. 


age-group  the  mortality  was  greater  for  negro  males  than  for  white  males  and 
females,  and  for  negro  females  than  for  white  males,  except  in  the  eighth 
decade,  and  for  white  females  except  in  the  age-period  80  years  and  over  in  1920. 

The  proportional  distribution  of  deaths  at  different  ages  to  the  total  deaths 
at  all  ages  for  each  year  from  1814  to  1920  will  now  be  studied.  The  number 
of  deaths  for  each  of  these  age-groups  and  their  ratio  per  hundred  to  the 
total  deaths  at  all  ages  are  given  for  individual  years  in  table  138  and  as 
averaged  for  5-  and  10-year  periods  in  table  139.  In  addition,  in  these  tables 
are  presented  the  number  and  proportion  of  deaths  recorded  as  occurring 
under  (before)  the  fifth  and  tenth,  twentieth,  thirtieth,  fortieth,  fiftieth, 
sixtieth,  and  seventieth  years  of  life,  and  70  years  and  over.  In  the  consid¬ 
eration  of  this  material  it  is  necessary  to  bear  constantly  in  mind  exactly  what 
it  does  and  does  not  represent,  for  otherwise  conclusions  open  to  serious  errors 
may  be  drawn.  The  figures  in  the  percentages  columns  indicate  solely  the  propor¬ 
tion  in  any  given  period  of  time  of  all  the  decedents  of  all  ages  that  fell 
within  certain  age-groups.  The  number  of  living  individuals  in  the  popula¬ 
tion  subject  to  the  risk  of  death  was  never,  of  course,  evenly  distributed  in 
respect  to  age-groupings,  and  the  proportional  distribution  of  living  individ- 


Table  138. — Percentage ,  by  separate  years,  of  deaths  by  specified  age-^periods  of  total  deaths 

from  all  causes,  from  1814  to  1920,  inclusive. 


1 

Year. 

Under  1 
vear. 

Between 

1  and  2 
years. 

Under  2 
years. 

2  to  4 
years. 

Under  5 
years. 

5  to  9 
years. 

Under 

10  years. 

10  to  19 
years. 

20  to  29 
years. 

30  to  39 
years. 

Deaths. 

Per  cent  of 
total  deaths. 

— 

Deaths. 

Per  cent  of 
total  deaths. 

Deaths. 

Per  cent  of 

total  deaths. 

Deaths. 

Per  cent  of 

total  deaths. 

Deaths. 

Per  cent  of 

total  deaths. 

Deaths. 

Per  cent  of 

total  deaths. 

Deaths. 

Per  cent  of 

total  deaths. 

Deaths. 

Per  cent  of 

total  deaths. 

Deaths. 

Per  cent  of 

total  deaths. 

Deaths. 

Per  cent  of 
total  deaths. 

1814 

•  • 

249 

21.6 

115 

10.0 

364 

31.6 

70 

6.1 

434 

37.7 

41 

3.6 

475 

41.2 

76 

6.6 

179 

15.5 

167 

14.5 

1815 

•  • 

448 

33.2 

73 

5.4 

521 

38.6 

92 

I  6.8 

613 

45.4 

70 

6.2 

683 

50.6 

192 

14.2 

174 

12.9 

107 

7.9 

1816 

•  • 

477 

36.2 

73 

5.5 

550 

41.8 

104 

7.9 

654 

49.7 

54 

4.1 

708 

63.8 

166 

12.6 

176 

13.4 

102 

7.7 

1817 

•  • 

430 

!  32.5 

141 

10.7 

571 

43.1 

59 

4.5 

630 

47.6 

39 

3.0 

669 

50.5 

108 

8.2 

198 

15.0 

133 

10.1 

1818 

«  . 

499 

29.1 

190 

11.1 

689 

40.2 

63 

3.1 

742 

43.2 

62 

3.6 

804 

46.9 

154 

9.0 

251 

14.6 

210 

12.2 

1819 

#  • 

516 

23.7 

252 

11.6 

768 

35.2 

129 

5.9 

897 

41.1 

147 

6.7 

1044 

47.9 

291 

13.3 

357 

16.4 

191 

8.8 

1820 

•  • 

390 

25.5 

116 

7.6 

506 

33.1 

48 

3.1 

554 

36.3 

77 

5.0 

631 

41.3 

113 

7.4 

177 

11.6 

210 

13.8 

1821 

•  • 

323 

16.9 

134 

7.0 

457 

23.9 

116 

6.1 

573 

30.0 

87 

4.6 

660 

34.6 

170 

8.9 

247 

12.9 

283 

14.8 

1822 

•  • 

347 

15.8 

154 

7.0 

501 

22.8 

114 

5.2 

615 

28.0 

91 

4.1 

706 

32.1 

232 

10.6 

325 

14.8 

341 

15.5 

1823 

#  , 

366 

18.3 

200 

10.0 

566 

28.3 

253 

12.7 

819 

41.0 

116 

5.8 

935 

46.8 

149 

7.5 

174 

8.7 

236 

11.8 

1824 

#  . 

310 

22.7 

78 

5.7 

388 

28.4 

106 

7.8 

494 

36.2 

57 

4.2 

551 

40.3 

112 

8.2 

139 

10.2 

164 

12.0 

1825 

.  # 

316 

21.8 

114 

7.9 

430 

29.6 

103 

7.1 

533 

36.7 

54 

3.7 

587 

40.4 

94 

6.5 

170 

11.7 

190 

13.1 

1826 

412 

22.6 

171 

9.4 

583 

32.0 

138 

7.6 

721 

39.5 

71 

3.9 

792 

43.4 

117 

6.4 

178 

9.8 

230 

12.6 

1827 

360 

25.8 

100 

7.2 

460 

32.9 

102 

7.3 

562 

40.2 

59 

4.2 

621 

44.4 

94 

6.7 

133 

9.5 

167 

12.0 

1828 

435 

27.0 

134 

8.3 

569 

35.3 

149 

9.2 

718 

44.5 

53 

3.3 

771 

47.8 

87 

5.4 

152 

9.4 

156 

9.7 

1829 

#  # 

428 

24.6 

126 

7.2 

554 

31.8 

167 

9.6 

721 

41.4 

55 

3.2 

776 

44.5 

111 

6.4 

177 

10.2 

188 

10.8 

1830 

406 

20.6 

184 

9.3 

590 

29.9 

232 

11.8 

822 

41.6 

110 

5.6 

932 

47.2 

123 

6.2 

193 

9.8 

202 

10.2 

1831 

514 

23.5 

166 

7.6 

680 

31.1 

244 

11.2 

924 

42.3 

125 

5.7 

1049 

48.0 

147 

6.7 

225 

10.3 

248 

11.4 

1832 

652 

19.0 

222 

6.5 

874 

25.5 

241 

7.0 

1115 

32.5 

117 

3.4 

1232 

36.0 

240 

7.0 

409 

11.9 

507 

14.8 

1833 

,  , 

625 

27.4 

224 

9.8 

849 

37.3 

274 

12.0 

1123 

49.3 

124 

5.4 

1247 

54.7 

136 

6.0 

213 

9.4 

228 

10.0 

1834 

•  • 

616 

23.7 

240 

9.2 

856 

32.9 

267 

10.3 

1123 

43.2 

117 

4.5 

1240 

47.7 

172 

6.6 

289 

11.1 

299 

11.5 

1835 

•  • 

461 

24.3 

176 

9.3 

637 

33.6 

141 

7.4 

778 

41.0 

58 

3.1 

836 

44.1 

120 

6.3 

189 

10.0 

223 

11.8 

1836 

•  • 

584 

26.6 

180 

8.2 

764 

34.9 

208 

9.5 

972 

44.3 

78 

3.6 

1050 

47.9 

109 

5.0 

203 

9.3 

227 

10.4 

1837 

•  • 

630 

25.0 

275 

10.9 

905 

35.9 

324 

12.9 

1229 

48.8 

148 

5.9 

1377 

54.7 

172 

6.8 

217 

8.6 

250 

9.9 

1838 

•  • 

655 

26.5 

256 

10.3 

911 

36.8 

246 

9.9 

1157 

46.7 

125 

5.1 

1282 

51.8 

154 

6.2 

238 

9.6 

276 

11.2 

1839 

•  • 

612 

27.1 

257 

11.4 

869 

38.5 

266 

11.8 

1135 

50.2 

99 

4.4 

1234 

54.6 

112 

5.0 

189 

8.4 

220 

9.7 

1840 

.  , 

532 

26.0 

182 

8.9 

714 

34.9 

183 

9.0 

897 

43.9 

93 

4.6 

990 

48.4 

123 

6.0 

205 

10.0 

226 

11.1 

1841 

651 

29.0 

217 

9.7 

868 

38.6 

208 

9.3 

1076 

47.9 

82 

3.7 

1158 

51.5 

123 

5.5 

214 

95 

231 

10.3 

1842 

•  • 

666 

26.9 

315 

12.7 

981 

39.6 

263 

10.6 

1244 

50.2 

106 

4.3 

1350 

54.5 

158 

6.4 

225 

9.1 

221 

8.9 

1843 

•  • 

682 

29.2 

229 

9.8 

911 

39.0 

153 

6.6 

1064 

45.6 

91 

3.9 

1155 

49.5 

138 

5.9 

251 

10.8 

234 

10.0 

1844 

•  • 

630 

23.6 

285 

10.7 

915 

34.3 

363 

13.6 

1278 

48.0 

158 

5.9 

1436 

53.9 

161 

6.0 

212 

8.0 

262 

9.8 

1845 

.  , 

830 

28.7 

208 

7.2 

1038 

35.8 

351 

12.1 

1389 

48.0 

149 

5.2 

1538 

53.1 

155 

5.4 

283 

9.8 

305 

10.5 

1846 

#  # 

786 

26.3 

287 

9.6 

1073 

35.8 

320 

10.7 

1393 

46.5 

167 

5.6 

1560 

52.1 

200 

6.7 

262 

8.8 

305 

10.2 

1847 

866 

25.4 

420 

12.3 

1286 

37.7 

376 

11.0 

1662 

48.7 

173 

5.1 

1835 

53.8 

151 

4.4 

320 

9.4 

.343 

10.1 

1848 

959 

24.8 

471 

12.2 

1430 

37.0 

508 

13.2 

1938 

50.2 

220 

5.7 

2158 

55.9 

207 

5.4 

352 

9.1 

349 

9.0 

1849 

,  , 

995 

23.9 

500 

12.0 

1495 

35.9 

414 

9.9 

1909 

45.8 

174 

4.2 

2083 

50.0 

237 

5.7 

435 

10.4 

433 

10.4 

1850 

1023 

24.3 

544 

12.9 

1567 

37.2 

488 

11.6 

2055 

48.8 

263 

6.3 

2318 

55.1 

247 

5.9 

399 

9.5 

381 

9.1 

1851 

1039 

24.9 

496 

11.9 

1535 

36.8 

467 

11.2 

2002 

48.0 

233 

6.6 

2235 

53.6 

206 

4.9 

429 

10.3 

391 

9.4 

1852 

#  # 

1203 

24.2 

667 

13.4 

1870 

37.7 

683 

13.8 

2553 

51.4 

315 

6.3 

2868 

57.8 

262 

5.3 

450 

9.1 

394 

7.9 

1853 

,  , 

1173 

24.4 

478 

10.0 

1651 

34.4 

595 

12.4 

2246 

46.8 

287 

6.0 

2533 

62.7 

270 

5.6 

457 

9.5 

488 

10.2 

1854 

,  # 

1235 

23.1 

656 

12.3 

1891 

35.4 

676 

12.7 

2567 

48.0 

312 

5.8 

2879 

53.9 

284 

5.3 

532 

10.0 

535 

10.0 

1855 

•  • 

1306 

25.7 

647 

12.8 

1953 

38.5 

500 

9.9 

2453 

48.3 

249 

4.9 

2702 

53.2 

286 

5.6 

484 

9.5 

462 

9.1 

1856 

•  • 

1471 

28.1 

758 

14.5 

2229 

42.6 

528 

10.1 

2757 

52.7 

229 

4.4 

2986 

57.1 

191 

3.7 

458 

8.8 

497 

9.5 

1857 

•  • 

1316 

25.7 

713 

13.9 

2029 

39.6 

627 

12.2 

2656 

51.9 

319 

6.2 

2975 

58.1 

244 

4.8 

411 

8.0 

405 

7.9 

1858 

•  • 

1283 

23.7 

738 

13.7 

2021 

37.4 

734 

13.6 

2755 

51.0 

388 

7.2 

3143 

58.1 

273 

5.1 

440 

8.1 

424 

7.8 

1859 

•  • 

1197 

25.6 

653 

14.0 

1850 

39.6 

553 

11.8 

2403 

51.4 

284 

6.1 

2687 

57.5 

241 

5.2 

354 

7.6 

393 

8.4 

1860 

•  • 

1227 

25.2 

616 

12.7 

1843 

37.9 

539 

11.1 

2382 

49.0 

234 

4.8 

2616 

53.8 

282 

5.8 

395 

8.1 

418 

8.6 

1861 

#  # 

1178 

24.6 

607 

12.7 

1785 

37.3 

515 

10.8 

2300 

48.0 

278 

5.8 

2578 

53.8 

224 

4.7 

420 

8.8 

399 

8.3 

1862 

1105 

21.4 

605 

11.7 

1710 

33.1 

757 

14.6 

2467 

47.7 

440 

8.5 

2907 

56.2 

278 

5.4 

394 

7.6 

390 

7.5 

1863 

#  # 

1180 

21.3 

545 

9.8 

1725 

31.1 

814 

14.7 

2539 

45.7 

413 

7.4 

2952 

53.2 

315 

5.7 

494 

8.9 

491 

8.9 

1864 

#  # 

1270 

22.4 

623 

11.0 

1893 

33.3 

840 

14.8 

2733 

48.1 

376 

6.6 

3109 

54.8 

333 

5.9 

478 

8.4 

479 

8.4 

1865 

1083 

23.1 

384 

8.2 

1467 

31.3 

615 

13.1 

2082 

44.4 

263 

5.6 

2345 

50.0 

269 

5.7 

518 

11.0 

397 

8.5 

1866 

#  # 

1285 

22.9 

587 

10.4 

1872 

33.3 

594 

10.6 

2468 

43.9 

294 

6.2 

2760 

49.1 

369 

6.6 

537 

9.6 

487 

8.7 

1867 

#  # 

1262 

23.9 

568 

10.8 

1830 

34.6 

622 

11.8 

2452 

46.4 

225 

4.3 

2677 

50.7 

226 

4.3 

519 

9.8 

469 

8.9 

1868 

.  m 

1615 

26.1 

778 

12.6 

2393 

38.7 

747 

12.1 

3140 

50.8 

295 

4.8 

3435 

55.6 

241 

3.9 

523 

8.5 

505 

8.2 

1869 

#  # 

1710 

26.3 

776 

11.9 

2486 

38.3 

753 

11.6 

3239 

49.9 

345 

5.3 

3584 

55.2 

276 

4.3 

593 

9.1 

490 

7.5 

1870 

•  • 

2098 

28.9 

855 

11.8 

2953 

40.7 

722 

9.9 

3675 

50.6 

301 

4.1 

3976 

54.7 

360 

5.0 

574 

7.9 

562 

7.7 

1871 

•  • 

1714 

24.0 

892 

12.5 

2606 

36.5 

850 

11.9 

3456 

48.4 

438 

6.1 

3894 

54.5 

414 

5.8 

577 

8.1 

543 

7.6 

1872 

•  • 

2090 

23.6 

1067 

12.1 

3157 

35.7 

1020 

11.5 

4177 

47.2 

566 

6.4 

4743 

53.6 

533 

6.0 

843 

9.5 

698 

7.9 

1873 

1923 

25.3 

759 

10.0 

2682 

35.3 

611 

8.1 

3293 

43.4 

369 

4.9 

3662 

48.3 

561 

7.4 

679 

9.0 

651 

8.6 

1874 

m  m 

2090 

28.3 

857 

11.6 

2947 

39.9 

577 

7.8 

3524 

47.8 

315 

4.3 

3839 

52.0 

435 

5.9 

643 

8.7 

560 

7.6 

1875 

m  m 

2216 

30.5 

705 

9.7 

2921 

40.2 

508 

7.0 

3429 

47.2 

373 

5.1 

3802 

52.4 

378 

5.2 

609 

8.4 

560 

7.7 

1876 

2317 

30.9 

925 

12.3 

3242 

43.2 

398 

5.3 

3640 

48.6 

424 

5.7 

4064 

54.2 

407 

5.4 

627 

8.4 

528 

7.0 

1877 

2182 

27.6 

1329 

16.8 

3511 

44.4 

518 

6.6 

4029 

50.9 

560 

7.1 

4589 

58.0 

423 

6.4 

579 

7.3 

526 

6.7 

1878 

1834 

27.2 

604 

9.0 

2438 

36.2 

444 

6.6 

2882 

42.8 

364 

5.4 

3246 

48.2 

356 

5.3 

596 

8.9 

560 

8.3 

1879 

2066 

27.1 

762 

10.0 

2828 

37.1 

557 

7.3 

3385 

44.4 

558 

7.3 

3943 

51.8 

347 

4.6 

644 

8.5 

559 

7.3 

1880 

m  m 

2329 

29.0 

701 

8.7 

3030 

37.7 

572 

7.1 

3602 

44.8 

541 

6.7 

4143 

51.5 

396 

4.9 

663 

8.2 

599 

7.5 

1881 

2364 

26.8 

864 

9.8 

8228 

36.6 

691 

7.8 

3919 

44.5 

665 

7.5 

4584 

52.0 

444 

5.0 

743 

8.4 

647 

7.3 

1882 

2198 

24.6 

844 

9.5 

3042 

34.1 

713 

8.0 

3755 

42.1 

800 

9.0 

4555 

51.0 

418 

4.7 

767 

8.6 

667 

7.5 

1883 

2351 

25.1 

881 

9.4 

3232 

34.5 

830 

8.9 

4062 

43.3 

796 

8.5 

4858 

51.8 

480 

5.1 

811 

9.7 

746 

8.0 

1884 

2354 

28.4 

783 

9.4 

3137 

37.8 

506 

6.1 

3643 

43.9 

472 

5.7 

4115 

50.0 

377 

4.6 

755 

9.1 

633 

7.6 

1885 

2196 

26.9 

650 

8.0 

2846 

34.9 

382 

4.7 

3228 

39.6 

363 

4.4 

3591 

44.0 

381 

4.7 

808 

9.9 

698 

8.6 

1886 

2393 

28.7 

760 

9.1 

3153 

37.8 

412 

4.9 

3565 

42.8 

347 

4.2 

3912 

47.0 

400 

4.8 

736 

8.8 

720 

8.6 

1887 

2420 

28.9 

685 

8.2 

3105 

37.1 

372 

4.4 

3477 

41.5 

307 

3.7 

3784 

45.2 

370 

4.4 

702 

8.4 

708 

8.5 

1888 

2624 

29.4 

787 

8.8 

3411 

38.2 

470 

5.3 

3881 

43.4 

345 

3.9 

4226 

47.3 

385 

4.3 

742 

8.3 

715 

8.0 

1889 

2578 

29.6 

614 

7.1 

3192 

36.7 

313 

3.6 

3505 

40.3 

321 

3.7 

3826 

44.0 

432 

5.0 

766 

8.8 

720 

8.8 

1890 

,  # 

2740 

26.9 

894 

8.8 

3634 

35.6 

483 

4.7 

4117 

40.4 

441 

4.3 

4558 

44.7 

479 

4.7 

843 

8.3 

834 

8.2 

I 


(521) 


Table  138. — Percentage,  by  separate  years,  of  deaths  by  specified  age-periods  of  total  deaths 
from  all  causes,  from.  1814  to  1920,  inclusive. — Continued. 


Under  1 

Between 

1  and  2 
years. 

Under  2 

2  to  4 

Under  5 

5  to  9 

Under 

10  to  19 

20  to  29 

30  to  39 

year. 

years- 

years. 

years. 

years. 

10  years. 

years. 

years. 

years. 

00 

CO 

CO 

00 

GO 

TO 

O  te 

-■5 

O  rt 

«4H 

O 

«*H 

o 

«*H  ^ 

°  d 

*-< 

o 

*H  ^ 

o  rt 

,  XX 

o-S 

-5 

o  <4 

4_j  GP 

-4-»  to 

-*->  0> 

-*->  . 

-M  . 

.4J  <V 

+->  • 

0) 

■M  0) 

M-. 

• 

CO 

0Q 

GX 

GX 

• 

fl  « 

e  2 

GX 

• 

G  “ 

C'O 

G  X) 

• 

G^3 

• 

A 

to  _ 
cj 

xx 

O 

«  a 

XX 

*-» 

Oh 

o  a 

XX 

-*-> 

O)  A 
o 

xx 

-*-> 

4/  A 

XX 

0)  r— H 

«  d 

XX 

-M 

o>  XX 

O  Xi 

XX 

4-> 

a)—. 

O  a 

XX 

+-> 

O  r—t 

v  Cj 

XX 

OP  — . 

o  cj 

d 

a 

<v 

t_  -4-> 

5  O 

cj 

<D 

S  o 

d 

to 

So 

Cj 

to 

1+  (U 

d 

to 

d 

to 

So 

cj 

O 

Cj 

a> 

<D 

Sh 

o>  o 

d 

O 

So 

£ 

Q 

Cm 

Q 

Q 

Q 

Q 

Dm'0 

Q 

Q 

Dh  ^ 

Q 

Cm 

Q 

Cm 

Q 

Qu 

1891 

2632 

26.1 

732 

7.3 

3364 

33.4 

546 

5.4 

3910 

38.8 

401 

4.0 

4311 

42.8 

445 

4.4 

746 

7.4 

746 

7.4 

1892 

2834 

26.8 

886 

8.4 

3720 

35.2 

723 

6.8 

4443 

42.0 

436 

4.1 

4879 

46.1 

464 

4.4 

847 

8.0 

816 

7.7 

1893 

2613 

27.4 

585 

6.1 

3198 

33.5 

406 

4.3 

3604 

37.7 

257 

2.7 

3861 

40.4 

505 

5.3 

782 

8.2 

784 

8.2 

1894 

2616 

27.6 

669 

7.1 

3285 

34.6 

476 

5.0 

3761 

39.7 

255 

2.7 

4016 

42.3 

459 

4.8 

778 

8.2 

780 

8.2 

1895 

2734 

26.5 

739 

7.2 

3473 

33.7 

553 

5.4 

4026 

39.1 

282 

2.7 

4308 

41.8 

480 

4.7 

775 

7.5 

848 

8.2 

1896 

2565 

25.9 

633 

6.4 

3198 

32.2 

530 

5.3 

3728 

37.6 

276 

2.8 

4004 

40.4 

452 

4.6 

831 

8.4 

828 

8.4 

1897 

2478 

26.6 

546 

5.9 

3024 

32.4 

486 

5.2 

3510 

37.6 

340 

3.6 

3850 

41.3 

430 

4.6 

694 

7.4 

823 

8.8 

1898 

2724 

26.2 

580 

5.6 

3304 

31.8 

635 

6.1 

3939 

37.9 

363 

3.5 

4302 

41.4 

479 

4.6 

853 

8.2 

809 

7.8 

1899 

2433 

24.0 

409 

4.0 

2842 

28.0 

477 

4.7 

3319 

32.7 

299 

3.0 

3618 

35.6 

510 

5.0 

886 

8.7 

907 

8.9 

1900 

2627 

24.6 

525 

4.9 

3152 

29.5 

543 

5.1 

3695 

34.5 

325 

3.0 

4020 

37.6 

483 

4.5 

916 

8.6 

947 

8.9 

1901 

2544 

24.3 

449 

4.3 

2993 

28.6 

398 

3.8 

3391 

32.4 

213 

2.0 

3604 

34.4 

422 

4.0 

942 

9.0 

991 

9.5 

1902 

2449 

23.9 

466 

4.6 

2915 

28.4 

412 

4.0 

3327 

32.5 

2:33 

2.3 

3560 

34.7 

453 

4.4 

922 

9.0 

894 

8.7 

1903 

2174 

21.4 

457 

4.5 

2631 

26.0 

471 

4.6 

3102 

30.6 

260 

2.6 

3362 

33.2 

475 

4.7 

867 

8.6 

920 

9.1 

1904 

2289 

21.2 

448 

4.1 

2737 

25.3 

418 

3.9 

3155 

29.2 

257 

2.4 

3412 

31.5 

488 

4.5 

987 

9.1 

986 

9.1 

1905 

2457 

23.0 

531 

5.0 

2988 

27.9 

477 

4.5 

3465 

32.4 

202 

1.9 

3667 

34.3 

436 

4.1 

942 

8.8 

975 

9.1 

1906 

2418 

22.5 

518 

4.8 

2936 

27.3 

383 

3.6 

3319 

30.9 

228 

2.1 

3547 

33.0 

466 

4.3 

957 

8.9 

977 

9.1 

1907 

2423 

21.7 

542 

4.8 

2965 

26.5 

368 

3.3 

3333 

29.8 

206 

1.8 

3539 

31.6 

438 

3.9 

1002 

9.0 

1106 

9.9 

1908 

2215 

21.2 

412 

4.0 

2627 

25.2 

340 

3.3 

2967 

28.4 

222 

2.1 

3189 

30.6 

441 

4.2 

910 

8.7 

960 

9.2 

1909 

2227 

21.5 

474 

4.6 

2701 

26.0 

370 

3.6 

3071 

29.6 

225 

2.2 

3296 

31.8 

390 

3.8 

915 

8.8 

933 

9.0 

1910 

2148 

20.0 

399 

3.7 

2547 

23.7 

344 

3.2 

2891 

26.9 

188 

1.8 

3079 

28.6 

451 

4.2 

883 

8.2 

1010 

9.4 

1911 

1958 

18.8 

425 

4.1 

2383 

22.9 

331 

3.2 

2714 

26.1 

205 

2.0 

2919 

28.1 

402 

3.9 

880 

8.5 

933 

9.0 

1912 

2026 

19.4 

361 

3.6 

2387 

22.9 

336 

3.2 

2723 

26.1 

171 

1.6 

2894 

27.7 

354 

3.4 

877 

8.4 

992 

9.5 

1913 

. 

2002 

19.7 

399 

3.9 

2401 

23.6 

331 

3.3 

2732 

26.9 

210 

2.1 

2942 

28.9 

327 

3.2 

844 

8.3 

925 

9.1 

1914 

1954 

18.5 

394 

3.7 

2348 

22.3 

284 

2.7 

2632 

24.9 

192 

1.8 

2824 

26.8 

351 

3.3 

840 

8.0 

939 

8.9 

1915 

1633 

16.3 

300 

3.0 

1933 

19.3 

248 

2.5 

2181 

21.8 

162 

1.6 

2343 

23.4 

354 

3.5 

765 

7.7 

945 

9.5 

1916 

1783 

16.6 

367 

3.4 

2150 

20.1 

305 

2.9 

2455 

22.9 

195 

1.8 

2650 

24.7 

359 

3.4 

815 

7.6 

972 

9.1 

1917 

1783 

15.7 

358 

3.2 

2141 

18.8 

305 

2.7 

2446 

21.5 

220 

1.9 

2666 

23.5 

427 

3.8 

910 

8.0 

1120 

9.9 

1918 

2259 

14.1 

766 

4.8 

3025 

18.9 

621 

3.9 

3646 

22.7 

365 

2.3 

4011 

25.0 

818 

5.1 

2288 

14.3 

2034 

12.7 

1919 

1711 

15.0 

350 

3.1 

2061 

18.0 

418 

3.7 

2479 

21.7 

227 

2.0 

2706 

23.7 

459 

4.0 

1058 

9.3 

1170 

10.2 

1920 

•• 

1960 

17.3 

379 

3.3 

2339 

20.6 

304 

2.7 

2643 

23.3 

202 

1.8 

2845 

25.1 

383 

3.4 

959 

8.4 

1030 

9.1 

Under 

40  to  49 

Under 

50  to  59 

60  to  69 

70  to  79 

80  to  89 

90  to  99 

100  years 

Unknown 

40  years* 

years. 

50  years. 

years. 

years. 

years. 

years. 

years. 

and  over. 

age. 

00 

Vi 

CO 

CO 

CO 

CO 

CO 

CO 

Cfi 

Gft 

*-  5 

5 

-5 

*mS 

c*h  ^ 

tfH  5 

O  rt 

O 

O  rt 

o  cj 

O  cj 

O  rt 

o  Ci 

o  rt 

o  rt 

_*_>  to 

to 

M_>  0) 

+j  <D 

o> 

-*->  CP 

xj  to 

• 

GX 

G  XI 

• 

C'O 

CO 

£  'O 

CO 

C  *0 

C'O 

GXJ 

C'O 

GX 

CX 

£ 

-M 

<V  r-i 

to  cj 

XX 

-4-> 

«  a) 

XX 

4-> 

to  »— H 

to  cj 

XX 

-4-> 

to  r— < 

o  Cj 

X 

<D  r-H 
to  cj 

XI 

+-> 

Or-* 
o  Cj 

XX 

+-> 

o  Cj 

XX 

-*-> 

<V  f-H 

o  Cj 

CJ  ^ 

^  C3 

XX 

to  ^H 
O  d 

d 

d 

Cj 

d 

cj 

d 

cj 

cj 

cj 

d 

^ 

ci 

►-  -ti 

to 

to 

to  O 

<u 

OP 

to  5 

op 

v  2 

to 

<U  O 

o> 

5 

0> 

Q)  ® 

0) 

0) 

O  ° 

to 

o  ° 

>< 

Q 

Cm^ 

a 

Cm  44 

a 

Cm  ^ 

Q 

Cm  ~ 

o 

D 

Gm*" 

Q 

Cm 

Q 

Dm 

Q 

Cm4" 

Q 

Cm  ^ 

1814 

897 

77.9 

115 

10.0 

1012 

87.9 

49 

4.3 

29 

2.5 

35 

3.0 

25 

2.2 

2 

0.2 

1815 

1156 

85.7 

58 

4.3 

1214 

90.0 

47 

3.5 

37 

2.7 

37 

2.7 

8 

0.6 

5 

0.4 

i 

o.i 

1816 

1152 

87.5 

53 

4.0 

1205 

91.5 

41 

3.1 

26 

2.0 

37 

2.8 

5 

0.4 

2 

0.2 

l 

0.1 

1817 

#  m 

1108 

83.7 

90 

6.8 

1198 

90.5 

39 

3.0 

24 

1.8 

34 

2.6 

23 

1.7 

4 

0.3 

2 

0.2 

# 

1818 

#  u 

1419 

82.7 

107 

6.2 

1526 

88.9 

69 

4.0 

43 

2.5 

37 

2.2 

26 

1.5 

13 

0.8 

2 

0.1 

•  •  •  • 

1819 

1883 

86.3 

117 

5.4 

2000 

91.7 

71 

3.3 

39 

1.8 

35 

1.6 

27 

1.2 

9 

0.4 

1 

0.1 

1820 

1131 

74.1 

133 

8.7 

1264 

82.8 

107 

7.0 

62 

4.1 

35 

2.3 

47 

3.1 

9 

0.6 

3 

0.2 

1821 

,  , 

1360 

71.2 

228 

11.9 

1588 

83.1 

134 

7.0 

83 

4.4 

48 

2.5 

37 

1.9 

15 

0.8 

6 

0.3 

•  •  •  • 

1822 

1604 

73.0 

239 

10.9 

1843 

83.9 

153 

7.0 

90 

4.1 

63 

2.9 

39 

1.8 

6 

0.3 

4 

0.2 

•  •  •  • 

1823 

1494 

74.7 

206 

10.3 

1700 

85.0 

131 

6.6 

82 

4.1 

52 

2.6 

28 

1.4 

6 

0.3 

1 

0.1 

•  •  •  • 

1824 

966 

70.7 

152 

11.1 

1118 

81.9 

79 

5.8 

74 

5.4 

56 

4.1 

29 

2.1 

7 

0.5 

3 

0.2 

•  •  •  • 

1825 

1041 

71.7 

139 

9.6 

1180 

81.2 

101 

7.0 

80 

5.5 

58 

4.0 

23 

1.6 

9 

0.6 

2 

0.1 

.... 

1826 

1317 

72.2 

178 

9.8 

1495 

81.9 

131 

7.2 

88 

4.8 

59 

3.2 

41 

2.3 

9 

0.6 

2 

0.1 

1827 

1015 

72.6 

131 

9.4 

1146 

82.0 

110 

7.9 

56 

4.0 

49 

3.5 

28 

2.0 

8 

0.6 

1 

0.1 

1828 

,  # 

1166 

72.3 

155 

9.6 

1321 

82.0 

106 

6.6 

83 

5.2 

51 

3.2 

40 

2.5 

7 

0.4 

4 

0.3 

1829 

1252 

71.8 

176 

10.1 

1428 

81.9 

122 

7.0 

87 

5.0 

65 

3.7 

32 

1.8 

6 

0.3 

3 

0.2 

1830 

1450 

73.5 

214 

10.8 

1664 

84.3 

126 

6.4 

85 

4.3 

57 

2.9 

34 

1.7 

4 

0.2 

4 

0.2 

1831 

m  # 

1669 

76.4 

179 

8.2 

1848 

84.6 

118 

5.4 

103 

4.7 

64 

2.9 

41 

1.9 

6 

0.3 

5 

0.2 

1832 

2388 

69.7 

386 

11.3 

2774 

80.9 

253 

7.4 

194 

5.7 

119 

3.5 

63 

1.8 

16 

0.5 

8 

0.2 

1833 

1824 

,  80.0 

158 

6.9 

1982 

87.0 

107 

4.7 

93 

4.1 

58 

2.5 

30 

1.3 

6 

0.3 

3 

0.1 

1834 

2000 

76.9 

217 

8.4 

2217 

85.3 

144 

5.5 

102 

3.9 

77 

3.0 

44 

1.7 

10 

0.4 

6 

0.2 

1835 

,  # 

i  1368 

72.2 

196 

10.3 

1564 

82.5 

122 

6.4 

81 

4.3 

76 

4.0 

39 

2.1 

8 

0.4 

6 

0.3 

1836 

1589 

72.5 

191 

8.7 

1780 

81.2 

147 

6.7 

124 

5.7 

81 

3.7 

41 

1.9 

11 

0.5 

8 

0.4 

1837 

I  2016 

80.1 

162 

6.4 

2178 

86.5 

103 

4.1 

115 

4.6 

80 

3.2 

35 

1.4 

6 

0.2 

1 

0.4 

1838 

1950 

78.8 

188 

7.6 

2138 

86.4 

124 

5.0 

98 

4.0 

61 

2.5 

44 

1.8 

8 

0.3 

3 

0.1 

1839 

#  # 

1755 

77.7 

148 

6.6 

i  1903 

84.2 

116 

5.1 

97 

4.3 

88 

3.9 

45 

2.0 

9 

0.4 

2 

0.1 

1840 

#  , 

1  1544 

75.5 

166 

8.1 

1710 

83.6 

126 

6.2 

82 

4.0 

76 

3.7 

44 

2.2 

5 

0.2 

2 

0.1 

1841 

1726 

76.8 

165 

7.3 

1891 

84.2 

120 

5.3 

107 

4.8 

73 

3.3 

45 

2.0 

8 

0.4 

3 

0.1 

1842 

m  # 

!  1954 

78.9 

190 

7.7 

2144 

86.6 

109 

4.4 

93 

3.8 

66 

2.7 

49 

2.0 

10 

0.4 

6 

0.2 

1843 

1778 

76.2 

166 

7.1 

1944 

83.3 

112 

4.8 

132 

5.7 

94 

4.0 

42 

1.8 

9 

0.4 

2 

0.1 

1844 

#  # 

2071 

l  77.7 

222 

8.3 

2293 

86.0 

126 

4.7 

110 

4.1 

72 

2.7 

42 

1.6 

13 

0.5 

9 

0.3 

1845 

•  • 

i  2281 

1  78.8 

228 

7.9 

2509 

86.6 

144 

5.0 

115 

4.0 

71 

2.5 

37 

1.3 

14 

0.5 

6 

0.2 

.  .  •  • 

(522) 


Table  138. — Percentage ,  by  separate  years,  of  deaths  by  specified  age-periods  of  total  deaths 

from  all  causes,  from  1814  to  1920,  inclusive. — Continued. 


Year. 

Under 

40  years. 

40  to  49 
years. 

Under 

50  years. 

50  to  59 
years. 

60  to  69 
years. 

70  to  79 
years. 

80  to  89 
yearB. 

90  to  99 
years. 

100  years 
and  over. 

Unknown 

age. 

Deaths. 

Per  cent  of 
total  deaths- 

Deaths. 

Per  cent  of 
total  deaths. 

Deaths. 

Per  cent  of 

total  deaths. 

Deaths. 

Per  cent  of 

total  deaths. 

Deaths. 

Per  cent  of 

total  deaths. 

Deaths. 

Per  cent  of 

total  deaths. 

Deaths. 

Per  cent  of 

total  deaths. 

Deaths. 

Per  cent  of 

tatal  deaths. 

Deaths. 

Per  cent  of 

total  deaths. 

Deaths- 

Per  cent  of 

total  deaths- 

1846 

9397 

77.7 

232 

7.8 

2559 

85.5 

135 

4.5 

129 

4  3 

94 

3  1 

59 

2.0 

15 

0.5 

3 

0.1 

1 

1847 

2649 

77.6 

259 

7.6 

2908 

85.2 

176 

6.2 

124 

3.6 

133 

3.9 

57 

2.0 

12 

0.4 

4 

0.1 

1848 

3066 

79.4 

261 

6.8 

3327 

86.2 

174 

4.5 

152 

3.9 

128 

3.3 

57 

1.5 

17 

0.4 

6 

0.2 

1849 

3188 

76.5 

336 

8.1 

3524 

84.6 

195 

4.7 

207 

5.0 

152 

3.7 

69 

1.4 

21 

0.5 

7 

0  2 

... 

1850 

3345 

79.5 

278 

6.6 

3623 

86.1 

220 

6.2 

157 

3.7 

134 

3.2 

59 

1.4 

13 

0.3 

4 

0.1 

1851 

3261 

78.2 

315 

7.6 

3576 

85.8 

189 

4.5 

176 

4.2 

166 

4.0 

49 

1.2 

10 

0.2 

3 

0.1 

1852 

3974 

80.0 

339 

6.8 

4313 

86.9 

215 

4.3 

202 

4.1 

144 

2.9 

66 

1.3 

19 

0.4 

6 

0.1 

1853 

3748 

78.0 

357 

7.4 

4105 

85.5 

221 

4.6 

228 

4.8 

146 

3.0 

79 

1.6 

21 

0.4 

3 

0.1 

1854 

4230 

79.2 

386 

7.2 

4616 

86.4 

253 

4.7 

237 

4  4 

143 

2.7 

65 

1.2 

17 

0.3 

12 

0.2 

1855 

3934 

77.5 

356 

7.0 

4290 

84.5 

281 

5.5 

221 

4.4 

169 

3.3 

82 

1.6 

25 

0.5 

7 

0.1 

1856 

4132 

79.0 

359 

6.9 

4491 

85.9 

225 

4.3 

222 

4  3 

183 

3.5 

86 

1.6 

15 

0.3 

7 

0.1 

1857 

4035 

78.8 

358 

7.0 

4393 

85.8 

235 

4.6 

225 

4.4 

163 

3.2 

73 

1.4 

23 

0.5 

8 

0.2 

•  .  ,  ( 

1858 

4280 

79.2 

346 

6.4 

4626 

85.6 

220 

4.1 

261 

4  8 

173 

3.2 

100 

1.9 

22 

0.4 

5 

0.1 

1859 

3675 

78.6 

298 

6.4 

3973 

85.0 

226 

4.8 

220 

4.7 

153 

3.3 

73 

1.6 

23 

0.5 

6 

0.1 

1860 

3711 

76.3 

323 

6.6 

4034 

82.9 

243 

6.0 

260 

5  3 

210 

4.3 

106 

2.2 

9 

0.2 

4 

0.1 

1861 

3621 

75.6 

366 

7.6 

3987 

83.2 

251 

5.2 

244 

5  1 

192 

4.0 

95 

2.0 

14 

0.3 

7 

0.2 

1862 

3969 

76.7 

373 

7.2 

4342 

83.9 

264 

5.1 

252 

4  9 

185 

3.6 

92 

1.8 

29 

0.6 

9 

0.2 

• 

1863 

4252 

76.6 

410 

7.4 

4662 

84.0 

268 

4.8 

286 

5  2 

202 

3.6 

107 

1.9 

17 

0.3 

9 

0.2 

1864 

4399 

77.5 

401 

7.1 

4800 

84.5 

282 

5.0 

263 

4  6 

204 

3.6 

101 

1.8 

22 

0.4 

6 

0.1 

1865 

3529 

75.2 

327 

7.0 

3856 

82.1 

275 

5.9 

267 

5.7 

179 

3.8 

85 

1.8 

27 

0.6 

6 

0.1 

1866 

4153 

73.9 

429 

7.6 

4582 

81.5 

356 

6.3 

321 

5.7 

218 

3.9 

123 

2.2 

21 

0.4 

2 

.04 

1867 

3891 

73.6 

455 

8.6 

4346 

82.3 

333 

6.3 

283 

5.4 

206 

3.9 

94 

1.8 

21 

0.4 

1 

.02 

1868 

4704 

76.1 

454 

7.3 

5158 

83.5 

386 

6.3 

299 

4.8 

203 

3.3 

112 

1.8 

19 

0.3 

1 

.02 

1869 

4943 

76.1 

482 

7.4 

5425 

83.5 

367 

5.7 

362 

5.6 

209 

3.2 

110 

1.7 

19 

0.3 

5 

0  1 

1870 

5472 

75.3 

500 

6.9 

5972 

82.2 

443 

6.1 

385 

5.3 

278 

3.8 

154 

2.1 

26 

0.4 

4 

0.1 

1871 

5498 

76.0 

493 

6.9 

5921 

82.9 

436 

6.1 

330 

4  6 

288 

4.0 

130 

1.8 

31 

0.4 

5 

0  1 

1872 

6817 

77.0 

614 

6.9 

7431 

83.9 

473 

5.3 

422 

4.8 

310 

3.5 

181 

2.0 

28 

0.3 

7 

0  1 

1873 

5553 

73.2 

548 

7.2 

6101 

80.4 

470 

6.2 

426 

5  6 

371 

4.9 

164 

2.2 

48 

0.6 

9 

0.1 

1874 

5477 

74.2 

472 

6.4 

5949 

80.6 

447 

6.1 

438 

5.9 

359 

4.9 

153 

2.1 

28 

0.4 

5 

0.1 

1875 

5349 

73.7 

464 

6.4 

5813 

80.1 

551 

7.6 

558 

7.7 

348 

4.8 

144 

2.0 

39 

0.5 

4 

0.1 

1876 

5626 

75.0 

482 

6.4 

6108 

81.5 

436 

6.8 

419 

5.6 

370 

4.9 

137 

1.8 

21 

0.3 

7 

0  1 

1877 

6117 

77.3 

436 

5.5 

6553 

82.9 

436 

5.5 

405 

5.1 

366 

4.6 

131 

1.7 

15 

0.2 

4 

0.1 

1878 

4758 

70.7 

455 

6.8 

5213 

77.4 

452 

6.7 

485 

7.2 

392 

5.8 

148 

2.2 

33 

0.5 

10 

0.2 

1879 

5493 

72.1 

489 

6.4 

5982 

78.5 

443 

5.8 

534 

7.0 

435 

5.7 

175 

2.3 

43 

0.6 

6 

0  1 

1880 

5801 

72.1 

529 

6.6 

6330 

78.7 

529 

6.6 

514 

6.4 

426 

5.3 

204 

2.5 

31 

0.4 

9 

0.1 

1881 

6418 

72.8 

507 

5.8 

6925 

78.6 

589 

6.7 

596 

6.8 

482 

5.5 

184 

2.1 

36 

0.4 

4 

0.1 

1882 

6407 

71.8 

561 

6.3 

6968 

78.1 

561 

6.3 

615 

6.9 

527 

5.9 

214 

2.4 

34 

0.4 

6 

0.1 

1883 

6895 

74.5 

574 

6.1 

7469 

80.6 

575 

6.1 

604 

6  4 

478 

5.1 

222 

2.4 

31 

0.3 

1 

01 

1884 

6880 

70.9 

547 

6.6 

6427 

77.5 

505 

6.1 

584 

7.0 

517 

6.2 

229 

2.8 

27 

0.3 

4 

0  1 

1885 

5478 

67.2 

566 

6.9 

6044 

74.1 

626 

7.7 

662 

8.1 

527 

6.5 

260 

3.2 

28 

0.3 

6 

0  1 

1886 

5768 

69.2 

568 

6.8 

6336 

76.0 

551 

6.6 

720 

8.6 

482 

5.8 

220 

2.6 

27 

0.3 

3 

04 

1887 

5564 

66.5 

644 

7.7 

6208 

74.2 

605 

7.2 

717 

8.6 

552 

6.6 

251 

3.0 

37 

0.4 

2 

02 

1888 

6068 

67.9 

645 

7.2 

6713 

75.1 

644 

7.2 

768 

8.6 

510 

5.7 

262 

2.9 

31 

0.4 

8 

0  1 

1889 

5744 

66.0 

661 

7.6 

6405 

73.6 

701 

8.0 

826 

9.5 

501 

5.8 

234 

2.7 

33 

0.4 

3 

03 

1890 

6714 

65.9 

784 

7.7 

7498 

73.5 

804 

7.9 

1085 

10.6 

498 

4.9 

264 

2.6 

41 

0.4 

8 

0  1 

1891 

62 18 

62.0 

789 

7.ii 

7037 

69.9 

829 

8.2 

928 

9.2 

806 

8.0 

402 

4.0 

67 

0.7 

4 

.04 

•  •  •  • 

1892 

7006 

66.2 

748 

7.1 

7754 

73.3 

798 

7.5 

873 

8.3 

728 

6.9 

371 

3.5 

53 

0.5 

5 

0  1 

1893 

5932 

62.1 

816 

8.5 

6748 

70.6 

780 

8.2 

866 

9.1 

742 

7.8 

366 

3.8 

44 

0.5 

8 

0  1 

1894 

6033 

63.6 

735 

7.8 

6768 

71.4 

801 

8.4 

832 

8.8 

701 

7.4 

322 

3.4 

59 

0.6 

3 

03 

1895 

6411 

62.2 

877 

8.5 

7288 

70.7 

849 

8.2 

924 

9.0 

798 

7.8 

379 

3.7 

57 

0.6 

6 

0  1 

1896 

6115 

61.7 

804 

8.1 

6919 

69.8 

881 

8.9 

958 

9.7 

791 

8.0 

323 

3.3 

42 

0.4 

5 

0  1 

1897 

5797 

62.1 

791 

8.5 

6588 

70.6 

814 

8.7 

831 

8.9 

737 

8.0 

313 

3.4 

41 

0.4 

5 

0  1 

1898 

6443 

62.0 

809 

7.8 

7252 

69.8 

917 

8.8 

881 

8.5 

834 

8.0 

396 

3.8 

57 

0.6 

0 

.02 

46 

0.4 

1899 

5921 

58.3 

884 

8.7 

6805 

67.0 

963 

9.5 

1037 

10.2 

895 

8.8 

377 

3.7 

68 

0.7 

2 

.02 

5 

0.1 

1900 

6366 

59.5 

952 

8.9 

7318 

68.4 

959 

9.0 

1084 

10.1 

860 

8.0 

407 

3.8 

70 

0.7 

2 

02 

1901 

5959 

56.9 

1029 

9.8 

6988 

66.7 

984 

9.4 

1109 

10.6 

929 

8.9 

405 

3.9 

57 

0.5 

7 

0.1 

•  •  •  •  • 

1902 

5829 

56.9 

982 

9.6 

6811 

66.4 

1000 

9.8 

1127 

11.0 

875 

8.5 

379 

3.7 

56 

0.6 

5 

0.1 

•  •  •  •  • 

1903 

5624 

55.5 

976 

9.6 

6600 

65.1 

1020 

10.1 

1079 

10.6 

947 

9.3 

416 

4.1 

58 

0.6 

17 

0.2 

4 

.04 

1904 

5873 

54.3 

1090 

10.1 

6963 

64.4 

1119 

10.3 

1203 

11.1 

1034 

9.6 

440 

4.1 

52 

0.5 

5 

0.1 

2 

.02 

1905 

6020 

56.3 

1042 

9.7 

7062 

66  0 

1056 

9.9 

1176 

11.0 

918 

8.6 

418 

3.9 

53 

0.5 

9 

0.1 

3 

.03 

1906 

5947 

55.3 

1164 

10.8 

7111 

66.1 

1104 

10.3 

1085 

10.1 

967 

9.0 

421 

3.9 

54 

0.5 

5 

0.1 

6 

0.1 

1907 

6085 

54.4 

1130 

10.1 

7215 

64.5 

1145 

10.2 

1275 

11.4 

993 

8.9 

494 

4.4 

61 

0.6 

4 

.04 

3 

.03 

1908 

5500 

52.7 

1055 

10.1 

6555 

62.8 

1127 

10.8 

1215 

11.6 

994 

9.5 

474 

4.5 

65 

0.6 

3 

.03 

2 

.02 

1909 

5534 

53.3 

1067 

10.3 

6601 

63.6 

1108 

10.7 

1192 

11.5 

982 

9.5 

433 

4.2 

53 

0.5 

6 

0.1 

1 

.01 

1910 

5423 

50.4 

1094 

10.2 

6517 

60.6 

1256 

11.7 

1352 

12.6 

1067 

9.9 

471 

4.4 

81 

0  8 

9 

0  1 

1911 

5134 

49  3 

1067 

10.3 

6201 

59.6 

1276 

12.3 

1249 

12.0 

1087 

10.5 

512 

4.9 

73 

0  7 

6 

0  1 

1912 

5117 

49.0 

1106 

10.6 

6223 

59.6 

1214 

11.6 

1351 

12.9 

1073 

10.3 

492 

4.7 

82 

0.8 

6 

0.1 

1 

.01 

1913 

5038 

49.6 

1119 

11.0 

6157 

60.6 

1194 

11.7 

1221 

12.0 

1037 

10.2 

484 

4.8 

72 

0.7 

3 

.03 

•  •  •  • 

•  •  •  •  • 

1914 

4954 

47.0 

1178 

11.2 

6132 

58.1 

1331 

12.6 

1379 

13.1 

1148 

10.9 

493 

4.7 

66 

0.6 

2 

.02 

1915 

4407 

44.1 

1152 

11.5 

5559 

55  6 

1414 

14.1 

1388 

13.9 

1114 

11.1 

460 

4.6 

62 

0.6 

5 

0.1 

1916 

4796 

44.7 

1276 

11.9 

6072 

56.6 

1426 

13.3 

1437 

13.4 

1212 

11.3 

492 

4.6 

79 

0.7 

1 

.01 

1917 

5123 

45.1 

1301 

11.5 

6424 

56.5 

1486 

13.1 

1585 

14.0 

1264 

11.1 

532 

4.7 

66 

0.6 

7 

0.1 

1918 

9151 

57.1 

1562 

9.7 

9714 

66.8 

1715 

10.7 

1620 

10.1 

1353 

8.4 

546 

3.4 

79 

0.5 

6 

.04 

1919 

5393 

47.2 

1353 

11.8 

6746 

59.0 

1412 

12.4 

1449 

12.7 

1268 

11.1 

495 

4.3 

61 

0.5 

3 

.03 

1920 

•  • 

5217 

45.9 

1174 

10.3 

6391 

56.3 

1448 

12  8 

1569 

13.8 

1325 

11.7 

539 

4.8 

81 

0.7 

3 

.03 

34 


(523) 


Table  139. — Average  'percentage  by  5-  and  10-year  periods,  of  deaths  by  specified  age 
periods  of  total  deaths  from  all  causes  from  1814  to  1920,  inclusive. 


Period. 

Under 

1  j'ear. 

Between  1 
and  2  years. 

Under 

2>  years. 

2  to  4 
years. 

Under 

5  years. 

5  to  9 
years- 

By  5-year 

periods. 

By  10-year 

periods. 

By  5-year 

periods* 

By  10-year 

periods* 

1 

By  5-year 

periods. 

- - - I 

By  10-year 

periods. 

| 

By  5-year 

periods. 

By  10-year 

periods. 

By  5-year 

periods. 

By  10-year 

periods. 

By  5-year 

periods. 

By  10-year 

periods. 

1814-1815  . 

27 

8 

•  •  •  • 

35 

•  •  •  • 

6 

*  •  »  • 

42 

4 

1816-1820  . 

29 

29 

9 

9 

39 

38 

5 

5 

44 

43 

4 

4 

1821-1825  . 

19 

•  •  •  • 

8 

•  •  •  • 

27 

>•  •  •  • 

8 

•  •  •  • 

34 

•  •  •  • 

4 

•  •  •  • 

1826-1830  . 

24 

22 

8 

8 

32 

29 

9 

8 

41 

38 

4 

4 

1831-1835  . 

24 

•  •  •  • 

8 

•  •  •  • 

32 

•  •  •  • 

10 

•  •  •  • 

42 

•  •  •  • 

4 

•  •  .  . 

1836-1840  . 

26 

25 

10 

9 

36 

34 

11 

10 

47 

44 

5 

5 

1841-1845  . 

27 

•  •  •  • 

10 

•  •  •  • 

37 

•  •  •  • 

10 

•  •  •  • 

48 

•  •  •  • 

5 

•  •  •  • 

1846-1850  . 

25 

26 

12 

11 

37 

37 

11 

11 

48 

48 

5 

5 

1851-1855  . 

24 

•  •  •  • 

12 

•  •  •  • 

37 

•  •  •  • 

12 

•  •  •  • 

49 

•  •  •  • 

6 

•  •  •  • 

1856-1860  . 

26 

25 

14 

13 

39 

38 

12 

12 

51 

50 

6 

6 

1861-1865  . 

23 

»  •  •  • 

11 

•  •  •  • 

33 

•  •  •  • 

14 

•  •  •  • 

47 

•  •  •  • 

7 

•  •  •  • 

1866-1870  . 

26 

24 

12 

11 

37 

35 

11 

12 

48 

48 

5 

6 

1871-1875  . 

26 

•  •  •  • 

11 

•  •  •  • 

38 

•  •  •  • 

9 

•  •  •  • 

47 

•  •  •  • 

5 

•  •  •  • 

1876-1880  . 

28 

27 

11 

11 

40 

39 

7 

8 

46 

47 

6 

6 

1881-1885  . 

26 

»  •  •  • 

9 

•  •  •  • 

36 

•  •  •  • 

7 

•  •  •  « 

43 

•  •  •  • 

7 

•  •  •  • 

1886-1890  . 

29 

28 

8 

9 

37 

36 

5 

6 

42 

42 

4 

5 

1891-1895  . 

27 

•  •  •  • 

7 

•  •  •  • 

34 

•  •  •  • 

5 

•  •  •  • 

39 

•  •  •  • 

3 

•  •  •  • 

1896-1900  . 

25 

'26 

5 

6 

31 

32 

5 

5 

36 

38 

3 

3 

1901-1905  . 

23 

•  •  •  • 

4 

•  •  •  • 

27 

•  •  •  • 

4 

•  •  •  • 

31 

•  •  •  • 

2 

•  •  •  • 

1906-1910  . 

21 

22 

4 

4 

26 

26 

3 

4 

29 

30 

2 

2 

1911-1915  . 

19 

•  •  •  • 

4 

•  •  •  • 

22 

•  •  •  • 

3 

•  •  •  • 

25 

•  •  •  • 

2 

•  •  •  • 

1916-1920  . 

16 

17 

4 

4 

19 

21 

3 

3 

22 

24 

2 

2 

* 

—126 

47 

— 

68 

43 

Period. 

Under 

10  years. 

10  to  19 
years. 

Under 

20  years. 

20  to  29 
years. 

Under 

30  years. 

30  to  39 
years. 

By  5-year 
periods- 

By  10-year 
periods- 

By  5-year 
periods. 

By  10-year 
periods. 

By  5-year 
periods. 

By  10-year 
periods. 

By  5-year 
periods. 

By  10-year 
periods. 

By  5-year 
periods. 

By  10-year 
periods. 

By  5-year 
periods. 

By  10-year 
periods. 

1814-1815  . 

46 

•  •  •  • 

10 

•  •  •  • 

56 

•  •  •  • 

14 

*  •  •  • 

71 

•  •  •  • 

11 

•  •  •  • 

1816-1820  . 

48 

47 

10 

10 

58 

58 

14 

14 

72 

72 

11 

11 

1821-1825  . 

39 

•  •  •  • 

8 

•  •  •  • 

47 

•  •  •  •  ' 

12 

•  •  •  • 

59 

•  •  •  • 

13 

•  •  •  • 

1826-1830  . 

45 

42 

6 

7 

52 

49 

10 

11 

61 

60 

11 

12 

1831-1835  . 

46 

•  •  •  • 

7 

•  •  •  • 

53 

•  •  •  • 

11 

•  •  •  • 

63 

•  •  •  • 

12 

•  •  •  • 

1836-1840  . 

51 

49 

6 

6 

57 

55 

9 

10 

66 

65 

10 

11 

1841-1845  . 

53 

•  •  •  • 

6 

•  •  •  • 

58 

•  •  •  • 

9 

•  •  •  • 

68 

•  •  •  • 

10 

•  •  •  • 

1846-1850  . 

53 

53 

6 

6 

59 

59 

9 

9 

68 

68 

10 

10 

1851-1855  . 

54 

•  •  •  • 

5 

•  •  •  • 

60 

•  •  •  • 

10 

»  •  •  • 

69 

•  •  •  • 

9 

•  •  •  • 

1856-1860  . 

57 

56 

5 

5 

62 

61 

8 

9 

70 

70 

8 

9 

1861-1865  . 

54 

•  «  *  • 

5 

•  •  •  • 

59 

•  •  •  • 

9 

»  ♦  •  • 

68 

•  •  •  • 

8 

•  •  •  • 

1866-1870  . 

53 

53 

5 

5 

58 

58 

9 

9 

67 

67 

8 

8 

1871-1875  . 

52 

•  •  •  • 

6 

•  •  •  • 

58 

•  •  •  • 

9 

•  •  •  • 

67 

•  •  •  • 

8 

•  •  •  • 

1876-1880  . 

53 

52 

5 

6 

58 

58 

8 

8 

66 

67 

7 

8 

1881-1885  . 

50 

•  •  •  • 

5 

•  •  •  • 

55 

•  •  •  • 

9 

•  •  •  • 

64 

•  •  •  • 

8 

•  •  •  • 

1886-1890  . 

46 

48 

5 

5 

50 

52 

9 

9 

59 

61 

8 

8 

1891-1895  . 

43 

•  •  •  • 

5 

•  •  •  • 

47 

•  •  •  • 

8 

•  •  •  « 

55 

•  •  •  • 

8 

•  •  •  • 

1896-1900  . 

39 

41 

5 

5 

44 

46 

8 

8 

52 

54 

9 

8 

1901-1905  . 

34 

•  •  •  • 

4 

•  •  •  • 

38 

•  •  •  • 

9 

%  •  •  • 

47 

•  •  •  • 

9 

•  •  •  • 

1906-1910  . 

31 

32 

4 

4 

35 

37 

9 

9 

44 

45 

9 

9 

1911-1915  . 

27 

•  •  •  • 

3 

•  •  *  • 

30 

•  •  •  • 

8 

•  •  •  • 

39 

.«  •  •  • 

9 

•  •  •  • 

1916-1920  . 

24 

26 

4 

4 

28 

29 

10 

9 

38 

38 

10 

10 

* 

-61 

-64 

-27 

• 

-18 

•  • 

•  • 

*  Percentage  of  changes  in  age  distribution  of  deaths  from  all  causes  dependent  upon  per¬ 
centage  of  changes  in  age  distribution  of  population  from  1850  to  1920. 

Plus  signs  denote  percentage  of  increase  and  minus  signs  denote  percentage  of  decrease. 


(524) 


Table  139. — Average  'percentage  by  5-  and  10-year  periods,  of  deaths  by  specified  age 
periods  of  total  deaths  from  all  causes  from  1814  to  1920 ,  inclusive. — Continued. 


Period. 

Under 

40  years. 

40  to  40 
years. 

Under 

50  years. 

60  to  59 
years. 

Under 

60  years. 

60  to  69 
years. 

By  5-year 

periods. 

By  10-year 

periods. 

By  5-year 

periods. 

By  10-year 

periods- 

By  5-year 

periods. 

By  10-year 

periods. 

By  5-year 

periods. 

By  10-year 

periods. 

By  5-year 

periods. 

By  10- year 

periods. 

By  5-year 

periods- 

By  10-year 

periods. 

1814-1815  . 

82 

7 

•  •  •  • 

89 

•  •  •  • 

4 

•  •  •  • 

93 

•  •  •  • 

3 

•  •  •  • 

1816-1820  . 

83 

83 

6 

6 

89 

89 

4 

4 

93 

93 

2 

2 

1821-1825  . 

72 

«  •  •  • 

11 

•  •  •  • 

83 

•  •  •  • 

7 

•  •  •  • 

90 

•  •  •  • 

5 

•  •  •  • 

1826-1830  . 

72 

72 

10 

10 

82 

83 

7 

7 

89 

90 

5 

5 

1831-1835  . 

75 

•  •  •  • 

9 

•  •  •  • 

84 

•  •  •  • 

6 

•  •  •  • 

90 

•  •  •  • 

5 

•  •  •  • 

1836-1840  . 

77 

76 

7 

8 

84 

84 

5 

6 

90 

90 

5 

5 

1841-1845  . 

78 

•  •  •  • 

8 

•  •  •  • 

85 

•  •  •  • 

5 

•  •  •  • 

90 

•  •  •  • 

4 

•  •  •  • 

1846-1850  . 

78 

78 

7 

8 

86 

85 

5 

5 

90 

90 

4 

4 

1851-18 55  . 

79 

•  •  •  • 

7 

•  •  •  • 

86 

t  •  •  • 

5 

•  •  •  * 

91 

•  •  •  • 

4 

•  •  •  • 

1856-1860  . 

78 

78 

7 

7 

85 

85 

5 

5 

90 

90 

5 

5 

1861-1865  . 

76 

•  •  •  • 

7 

•  •  •  • 

84 

•  •  •  • 

5 

•  •  •  • 

89 

•  •  •  • 

5 

•  •  •  • 

1866-1870  . 

75 

76 

8 

7 

83 

83 

6 

6 

89 

89 

5 

5 

1871-1875  . 

75 

•  •  •  • 

7 

•  •  •  • 

82 

•  •  •  • 

6 

•  •  •  • 

88 

•  «  •  • 

6 

•  •  •  • 

1876-1880  . 

73 

74 

6 

7 

80 

81 

6 

6 

86 

87 

6 

6 

1881-1885  . 

71 

•  •  •  • 

6 

•  •  •  • 

78 

•  •  •  • 

7 

•  •  •  • 

84 

•  •  •  • 

7 

•  •  •  • 

1886-1890  . 

67 

69 

7 

7 

74 

76 

7 

7 

82 

83 

9 

8 

1891-1895  . 

63 

»  •  •  • 

8 

•  •  •  • 

71 

•  •  •  • 

8 

•  •  •  • 

79 

•  •  •  • 

9 

•  •  •  • 

1896-1900  . 

61 

62 

8 

8 

69 

70 

9 

9 

78 

79 

9 

9 

1901-1905  . 

56 

•  •  •  • 

10 

•  •  •  • 

66 

•  •  •  • 

10 

•  •  •  • 

76 

•  •  •  • 

11 

•  •  •  • 

1906-1910  . 

53 

55 

10 

10 

64 

65 

11 

10 

74 

75 

11 

11 

1911-1915  . 

48 

•  •  •  • 

11 

•  •  •  • 

59 

•  •  •  • 

12 

•  •  •  • 

71 

•  •  •  • 

13 

•  •  •  • 

1916-1920  . 

48 

48 

11 

11 

59 

59 

12 

12 

71 

71 

13 

13 

• 

—  14 

+127 

— 

8 

+55 

4 

+47 

Period. 

Under 

70  years. 

70  years 
and  over. 

70  to  79 
years. 

80  to  89 
years. 

90  to  99 
years- 

100  years 
and  over. 

By  5-year 
periods. 

By  10-year 
periods. 

By  5-year 
periods. 

‘  ■ 

By  10-year 
periods. 

By  5-year 
periods. 

By  10-year 
periods. 

By  5-year 
periods. 

By  10-year 
periods. 

By  5-year 
periods. 

By  10-year 
periods. 

By  5-.vear 
periods. 

By  10-year 
periods- 

1814-1815  . 

95 

•  •  •  • 

5 

•  •  •  • 

3 

•  • 

1 

•  •  •  • 

.27 

.04 

1816-1820  . 

96 

96 

4 

4 

2 

2 

2 

2 

.44 

.39 

.12 

.07 

1821-1825  . 

94 

•  •  •  • 

6 

•  •  •  • 

3 

•  • 

,  # 

2 

•  •  •  • 

.50 

•  •  •  • 

.17 

.... 

1826-1830  . 

94 

94 

6 

6 

3 

3 

2 

2 

.41 

.45 

.16 

.17 

1831-1835  . 

94 

•  •  •  • 

6 

•  •  •  • 

3 

•  • 

#  # 

2 

•  •  •  • 

.36 

•  •  •  • 

.23 

•  •  •  • 

1836-1840  . 

94 

94 

6 

6 

3 

3 

2 

2 

.34 

.35 

.14 

.19 

1841-1845  . 

95 

•  •  •  • 

5 

•  •  •  • 

3 

•  • 

2 

•  •  •  • 

.42 

•  •  •  • 

.20 

•  •  •  • 

1846-1850  . 

94 

95 

6 

5 

3 

3 

2 

2 

.42 

.42 

.13 

.17 

1851-1855  . 

95 

•  •  •  • 

5 

•  •  •  « 

3 

•  • 

1 

•  •  •  • 

.37 

.... 

.12 

•  •  •  • 

1856-1860  . 

94 

95 

6 

5 

3 

3 

2 

2 

.36 

.37 

.12 

.12 

1861-1865  . 

94 

•  •  •  • 

6 

•  •  •  • 

4 

•  • 

#  # 

2 

•  •  •  • 

.43 

.... 

.16 

•  •  •  • 

1866-1870  . 

94 

94 

6 

6 

4 

4 

2 

2 

.35 

.39 

.04 

.10 

1871-1875  . 

94 

•  •  •  • 

7 

•  •  •  • 

4 

•  • 

•  # 

2 

•  •  •  • 

.46 

.... 

.08 

.... 

1876-1880  . 

92 

93 

8 

7 

5 

5 

2 

2 

.38 

.42 

.10 

.09 

1881-1885  . 

91 

•  •  •  • 

9 

•  •  •  • 

6 

#  # 

3 

•  •  •  • 

.36 

•  •  •  • 

.05 

•  •  •  • 

1886-1890  . 

91 

91 

9 

9 

6 

6 

3 

3 

.38 

.37 

.05 

.05 

1891-1895  . 

88 

•  •  •  • 

12 

•  •  •  • 

8 

•  • 

#  # 

4 

•  •  •  • 

.56 

•  •  •  • 

.05 

•  •  •  • 

1896-1900  . 

88 

88 

12 

12 

8 

8 

4 

4 

.55 

.56 

.03 

.04 

1901-1905  . 

86 

•  •  •  • 

14 

•  •  •  • 

9 

•  • 

4 

•  •  •  • 

.53 

»  •  •  • 

.08 

•  •  •  • 

1906-1910  . 

86 

86 

14 

14 

9 

9 

4 

4 

.59 

.59 

.05 

.07 

1911-1915  . 

84 

•  •  •  • 

16 

•  •  •  • 

11 

•  • 

5 

•  •  •  • 

.69 

.... 

.04 

.... 

1916-1920  . 

84 

84 

16 

16 

11 

11 

4 

5 

.61 

.65 

.03 

.04 

* 

L 

+90 

+37 

+67 

*  Percentage  of  changes  in  age  distribution  of  deaths  from  all  causes  dependent  upon  per¬ 
centage  of  changes  in  age  distribution  of  population  from  1850  to  1920. 

Plus  signs  denote  percentage  of  increase  and  minus  signs  denote  percentage  of  decrease. 


(525) 


526  PUBLIC  HEALTH  ADMINISTRATION",  ETC.,  IN  BALTIMORE 

uals  in  the  whole  population  in  each  age-group  was  subject,  both  as  regards 
shorter  and  longer  periods  of  time  (as  the  result  of  changes  in  the  birth, 
immigration,  and  death-rates,  general  as  well  as  selective  for  age),  to  varia¬ 
tions  not  inconsiderable.  To  illustrate:  for  any  particular  age-group  at  one 
time  the  larger  proportion  of  individuals  or  of  deaths,  as  the  case  may  be,  may 
fall  in  its  earlier  portion,  or  at  its  center,  and  at  another  time  may  cluster 
near  its  upper  boundary.  Other  things  remaining  equal,  the  broader  the  age- 
group,  the  wider  the  opportunities  for  such  variations. 

It  is  evident  that  a  small  percentage  of  deaths  in  one  or  more  age-groups 
in  one  year  or  in  a  short  series  of  years  might  well  be  due  in  large  part,  at 
least,  to  an  unusually  heavy  depletion  by  death  in  the  period  immediately 
preceding,  or  conversely,  that  a  large  increase  of  deaths  at  one  period  in  a 
particular  age-group  might  be  causally  associated  with  the  accumulation  in  it 
during  a  period  of  low  mortality  of  a  comparatively  large  number  of  vul- 
nerables.  However,  these  objections  apply  less  weightily  to  the  consideration 
of  the  results  as  measured  for  single  age-groupings  over  long  periods  or  for 
multiple  age-groupings,  as  for  instance,  the  total  for  ail  ages  below  the 
thirtieth,  fortieth,  or  fiftieth  years  of  life,  over  either  long  or  short  intervals 
of  time.  As,  on  the  whole,  changes  in  the  proportional  age  distribution  in 
respect  of  10-year  age  groupings,  though  often  considerable  in  the  aggregate, 
took  place  comparatively  slowly,  if  the  ratio  of  deaths  in  large  age-groupings 
to  the  total  deaths  at  all  ages  follows  definite  trends  over  long  periods  of 
time,  it  would  appear  that  errors  inherent  in  this  method  must  be  largely 
balanced  and  the  logical  inferences  drawn  from  the  evidence  will  be  measur¬ 
ably  correct.  If  these  tally  in  general  tenor  with  rates  specific  for  age  that 
have  been  obtained  for  the  census  years,  their  value  will  be  greatly  increased. 
In  comparing  these  results  with  similar  material  for  other  cities,  it  is  essential 
to  recall  that  these  figures  include  deaths  in  a  mixed  population  of  whites  and 
negroes,  and  that  with  the  exception  of  certain  short  periods  the  mortality 
in  the  latter  was  always  much  higher  than  in  the  former. 

From  even  the  most  cursory  study  of  table  138  it  is  evident  that  the  percent¬ 
ages  of  deaths  in  the  various  age-groupings  often  fluctuate  within  relatively 
wide  limits,  that  on  the  whole  in  the  earlier  and  mid-years  of  the  period  under 
consideration,  the  proportion  of  deaths  in  the  age-groups  below  middle  life 
was  very  high  and  the  proportion  above  this  period  of  life  was  relatively  low. 
After  1875,  especially,  the  latter  group  gained  and  the  former  lost  in  impor¬ 
tance.  In  1816,  one  of  the  most  unfavorable  years  for  the  earlier  years  of 
life,  the  percentages  of  deaths  in  the  various  important  age-groups  were: 
Under  1  year  36.2,  under  5  years  49.7,  under  10  years  53.8,  under  40  years 
87.5,  under  50  years  91.5.  In  1822  the  percentages  of  deaths  had  fallen, 
under  1  year  to  15.8,  under  5  years  to  28,  under  10  years  to  32,  under  40  years 
to  73,  and  under  50  years  to  83.9.  In  1875  the  proportions  were:  Under  1 
year  30.5,  under  5  years  47.2,  under  10  years  54.2,  under  40  years  73.7, 
under  50  years  80.1.  By  1920  the  proportions  were  markedly  changed,  as 
follows:  Under  1  year  17.5,  under  5  years  23.3,  under  10  years  25.1,  under 
40  years  45.9,  under  50  years  56.3.  And  similarly,  in  other  years,  very  great 
variations  occurred  in  the  proportion  of  deaths  in  all  the  age-groups. 

Turning  to  the  percentages  averaged  for  5-  and  10-year  periods  (table 
139  and  graphs  39  and  40),  it  will  be  observed  that  the  proportion  of  deaths 


GENERAL  CONCLUSIONS 


527 


YEAR 

Graph  39  (from  table  139).  Averages,  by  10-year  periods,  of  percentages 
of  deaths  by  specified  age-periods  of  total  deaths  from  all  causes,  from  1814 
to  1920,  inclusive. 


YEAR 

Graph  40  (from  table  139).  Averages,  by  10-year  periods,  of  the  per¬ 
centages  of  deaths  under  certain  ages  to  total  deaths,  from  1814  to  1920, 
inclusive. 


528  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

within  the  various  age-groups,  as  well  as  under  certain  ages,  followed  very 
definite  trends.  On  account  of  the  greater  smoothness  of  their  curves,  discus¬ 
sion  will  be  confined  to  the  rates  as  averaged,  for  10-year  periods.  For  the  age- 
groups  under  1,  0  to  5,  and  0  to  10,  after  a  decided  decline  between  1820  and 
1830,  the  percentage  rose  for  several  decades  (until  1860  in  the  two  latter 
groups)  and  thereafter  declined  continuously  and  markedly  to  the  end.  In 
the  second  decade  of  life,  except  for  a  slight  rise  in  1880,  the  decline  in  the 
proportion  of  deaths  was  continuous.  A  similar  fall  characterized  the  course 
for  the  age-group  20  to  29  years  until  1900,  after  which  the  proportion  rose 
in  a  moderate  degree.  For  all  the  age-groups  above  the  thirtieth  year  there 
was  a  considerable  rise  between  1820  and  1830,  followed  by  a  gradual  decline 
to  a  lower  level,  reached  usually  between  1860  and  1880.  This  decline  was 
invariably  succeeded  by  an  ascent  which,  in  the  higher  age-groups,  was  very 
considerable.  The  proportionate  increase  for  the  various  decades  of  life 
between  1850  and  1920,  in  percentages,  was  for  the  fourth,  nothing;  in  the 
fifth,  37;  in  the  sixth,  140;  in  the  seventh,  222;  in  the  eighth,  267;  in  the 
ninth,  100.  Similarly,  the  percentage  of  decline  was  in  the  first  decade,  51; 
in  the  second,  33,  and  in  the  third,  nothing. 

Following,  now,  the  course  of  the  percentages  of  deaths  under  1,  2,  5,  and 
10  years  and  each  succeeding  decade  of  life  to  the  sixtieth  year,  it  is  found 
that  for  each  category  there  was  a  sharp  decline  between  1820  and  1830, 
followed  by  a  gradual  ascent  to  a  peak  reached  in  1850  or  1860,  and  suc¬ 
ceeded  by  a  continuous  and  even  decline  to  1920.  The  percentages  of  this 
decline  were  from  1850  to  1920,  under  1  year,  41;  under  2  years,  45;  under 
the  fifth  and  tenth  years,  45 ;  under  the  twentieth  year,  50 ;  under  the  thirtieth, 
47 ;  under  the  fortieth,  42 ;  under  the  fiftieth,  34 ;  under  the  sixtieth,  24 ; 
under  the  seventieth,  13.  In  this  same  period  there  was  an  increase  of  300 
in  the  percentage  of  deaths  in  the  age-group  70  years  and  over.  When  allow¬ 
ances  are  made  for  the  changes  in  the  proportional  distribution  of  the  popu¬ 
lation  among  the  various  age-groups  in  the  census  years  1850  to  1920  (see 
table  10)  it  appears  that  in  this  period  the  percentages  of  decline  of  these 
death-ratios  dependent  upon  the  age-factor  alone  were  for  under  1  year,  48 ; 
from  1  to  4  years,  41;  under  5  years,  67;  from  5  to  9  years,  34;  and  the  first 
two  decades  of  life,  61  and  64,  respectively.  Between  the  twentieth  and 
fortieth  years  of  life  the  death  ratios  did  not  vary  and  the  percentages  of 
change  in  these  age-groups  of  the  population  were  insignificant.  In  the  fifth, 
sixth,  seventh,  and  eighth  decades  and  80  years  and  over,  127,  55,  47,  37,  and 
67  per  cent,  respectively,  of  the  increase  in  the  death  ratios  were  attributable 
to  the  percentages  of  proportional  increases  in  the  corresponding  age-groups 
of  the  population.  From  the  foregoing  analysis  the  conclusion  is  warranted 
that,  when  corrected  for  the  known  changes  in  the  age  distribution  of  the  popu¬ 
lation,  the  trends  of  these  ratios  accord  in  a  general  way  with  the  courses  of  the 
rates  specific  for  the  corresponding  age  groups  for  the  census  years,  confirm  the 
deductions  drawn  from  the  latter,  and  indicate  the  proportion  of  the  observed 
decline  in  the  total  mortality  which  was  due  to  causes  other  than  the  age 
factor. 

At  this  point  it  will  be  instructive  to  consider  the  influence  upon  the 
mortality-rate  from  all  causes  of  those  great  groups  of  maladies  whose  courses 
may  be  followed  from  the  beginning.  This  comparison,  in  rates  averaged  for 


GENERAL  CONCLUSIONS 


529 


5-year  periods,  is  made  in  graph  41.  Of  the  seven  groups,  each  composed  of 
several  distinct  affections,  five  belong  without  question  wholly  to  the  infec¬ 
tions.  Of  the  remaining  two,  in  one,  violence,  infection  plays  primarily  no 
part,  and  in  the  other,  certain  diseases  peculiar  to  infancy,  the  role  of  infec¬ 
tions  is  a  subsidiary  one.  In  most  of  these  groups  there  is  at  least  one  affection 
the  death-rate  of  which  might  have  been  favorably  influenced  within  the 
period  under  discussion  by  either  medical  treatment  or  by  some  forms  of 
administrative  activities.  It  will  be  observed  that  the  curve  for  all  causes  of 
death  presents  five  distinct  wraves:  the  first  from  1812  to  1830,  the  second 
from  1831  to  1845,  the  third  from  1846  to  1865,  the  fourth  from  1866  to 


Graph  41  (from  tables  18,  20,  43,  61,  79,  123,  129,  and  133).  A  comparison, 
in  crude  rates  averaged  for  5-year  periods,  of  the  contribution  of  seven 
important  groups  of  diseases  to  the  total  mortality  from  all  causes,  from 
1812  to  1920.  inclusive. 


1880,  and  the  fifth  from  1881  to  1915.  In  comparing  the  curves  for  each 
of  these  groups  with  that  for  all  causes,  there  appear  certain  striking  corre¬ 
spondences  which  in  large  part  may  explain  the  latter.  In  the  first  wave  the 
rise  and  fall  in  the  mortality-rates  for  all  causes  is  definitely  assoeiatecl  with 
similar  changes  in  the  rates  for  insect-borne,  intestinal,  and  acute  respiratory 
diseases  and  for  tuberculosis.  Violence  conforms  in  less  degree,  but  exanthe¬ 
matous  diseases  and  certain  diseases  of  infancy  not  at  all.  In  the  second  wave, 
intestinal  and  exanthematous  diseases,  affections  of  early  infancy  and  tuber¬ 
culosis  conform  distinctly  with  all  causes.  In  the  third  wave,  while  intestinal, 
respiratory,  and  exanthematous  diseases  follow  the  curve  for  all  causes  most 
conspicuously  and  exactly,  all  the  other  groups,  except  early  infancy,  display 


530  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

rises  and  falls.  The  same  phenomena  are  repeated  in  the  fourth  wave.  In 
the  gradual  descent  between  1881  and  1915  in  the  curve  for  all  causes,  insect- 
borne,  intestinal,  and  exanthematous  diseases  showed  marked  recessions,  while 
tuberculosis,  acute  respiratory  diseases,  and  diseases  of  early  infancy  declined 
sensibly.  Violence,  on  the  other  hand,  rose  gradually.  The  distinct  rise  since 
1916  in  the  rate  for  all  causes  was  associated  very  definitely  with  increases  in 
the  rates  for  acute  respiratory  and  the  exanthematous  diseases  (influenza) 
and  violence. 

While  it  may  not  be  claimed  that  these  groups  of  affections  were  the  sole 
causes,  it  does  appear  that  they  were  mainly  responsible  for  the  high  mortality- 
rates,  and  that,  embracing  as  they  do  all  the  more  important  factors  concerned 
in  rapidly  fluctuating  rates,  they  represent  the  main  elements  of  elasticity  in 
the  total  mortality-rates.  Other  things  remaining  equal,  it  is  mainly  through 
these  groups  of  causes  that  the  total  death-rate  may  be  seriously  affected  by 
either  natural  or  artificial  means,  so  far  known.  As  they  have  regressed  in 
importance  as  causes  of  death,  the  total  mortality-rates  have  not  only  fallen, 
but  tended  to  stabilize.  As  these  groups  have  both  contributed  in  very  large 
proportion  to  the  total  deaths  and  represented  the  chief  factors  of  elasticity 
in  the  death-rate  from  all  causes,  their  disappearance,  or  even  their  further 
serious  diminution  in  lethal  force,  would  result  in  the  stabilization  of  the  total 
death-rate  at  a  yet  lower  level. 


Chapter  XX. — Summary  and  Conclusions. 

The  febrile  diseases;  Affections  peculiar  to  child-birth  and  to  early  in¬ 
fancy;  Violence;  The  chronic  organic  diseases.  (Tables  140  and  141.) 

It  now  remains  to  summarize  and  to  correlate  the  essential  facts  collected 
and  analyzed  in  the  foregoing  chapters,  with  the  design  of  reaching  general¬ 
izations  from  which  instructive  lessons  may  be  deduced. 

The  febrile  diseases. — On  both  historical  and  practical  grounds  it  is  con¬ 
venient  to  consider  first  the  febrile  diseases,  concerning  which  certain  impor¬ 
tant  facts  stand  out  with  striking  clearness.  Without  exception,  the  course  of 
each  particular  disease  studied  has  been  marked  by  advances  and  recessions 
of  mortality  which  have  flowed  and  ebbed  in  series  of  tides  of  uneven  volume 
and  force.  A  few  have  advanced  and  receded  like  tidal  waves;  others  have 
pursued  a  less  uneven  course.  For  many  of  them  similar  courses  can  be 
traced  for  morbidity.  When  measured  by  rates  specific  for  age,  race,  and  sex 
these  characteristics  persist.  For  certain  groups  of  these  diseases,  especially 
those  in  which  transmission  appears  to  be  confined  largely  if  not  entirely  to 
direct  contact  through  individuals,  these  characters,  while  modified  in  degree, 
have  not  been  changed  in  quality  by  any  artificial  barriers  that  have  been  set 
up  from  time  to  time.  In  the  case  of  each  particular  disease  of  this  class,  except 
pneumonia  and  influenza,  that  can  be  followed  continuously  over  a  long  term 
of  years,  mortality-rates  have  fallen  conspicuously  since  1885  or  1890,  and  by 
the  end  of  the  period  embraced  in  this  study  are  at  or  near  their  lowest  ebb. 
In  the  case  of  all  of  the  important  febrile  diseases,  importation  from  without 
has  been  an  important  factor.  As  between  the  two  great  groups  of  these 
diseases,  these  changes  in  incidence  and  mortality  have  occurred,  on  the  whole, 
in  different  fashions  for  the  nuisance  and  the  contactive  diseases;  in  the 
former  the  declines  were  gradual,  while  in  the  latter,  as  measured  in  terms  of 
mortality  at  least,  the  decreases  were  comparatively  abrupt. 

Considering  first  the  diseases  whose  spread  is  governed  so  largely  by  environ¬ 
mental  conditions,  the  nuisance  diseases  in  the  broad  sense,  attempts  at  arti¬ 
ficial  interference  were  rewarded  by  a  considerable  measure  of  success  after 
a  long  and  poorly  managed  campaign.  The  efforts,  correct  in  principle,  directed 
against  the  mosquito-borne  diseases,  were  more  determined  and  persistent, 
and  consequently  were  sooner  affective.  However,  owing  to  the  natural  history 
of  these  diseases,  the  problems  were  simpler.  With  yellow  fever  the  obstacles 
to  be  overcome  were  less  difficult,  for  the  following  reasons :  The  high  case- 
fatality  rate  and  short  interval  between  invasion  and  death  diminished  oppor¬ 
tunity  of  spread;  the  apparent  inability  of  the  stegomyia  mosquito  to  breed 
in  numbers  except  at  Fell’s  Point,  long  the  sole  place  of  docking  of  ships 
from  infected  ports,  tended  to  confine  the  disease  to  this  locality  except  under 
unusual  conditions  of  wind;  the  complete  recovery  without  becoming  carriers 
of  those  who  survived,  and  the  effect  of  cold  upon  this  species  of  mosquito, 
cmbined  to  make  it  practically  impossible  for  the  disease  to  survive  the  winter; 

531 


532  PUBLIC  HEALTH  ADMINISTRATION",  ETC.,  IN  BALTIMORE 

the  disease  was  usually  imported  over  a  great  distance,  from  places  where  its 
prevalence  has  greatly  diminished  and  from  which  trade  has  decreased. 

Malaria,  on  the  other  hand,  was  indigenous,  and  conditions  for  frequent 
importation  from  near  and  far  were  peculiarly  favorable;  case-fatality  also 
was  relatively  lower,  and  many  infected  individuals  carried  the  parasites  over 
the  winter  season;  and  the  malaria-carrying  species  of  mosquitoes  were  abun¬ 
dant  and  widely  spread  in  the  city,  over  a  large  part  of  which  conditions  were 
for  many  years  particularly  favorable  for  their  multiplication.  The  influence 
of  importation  of  the  disease  upon  both  prevalence  and  severity  of  attack 
and  of  cinchona  upon  its  cure  and  final  eradication  can  hardly  be  over¬ 
estimated.  When  the  disease  was  at  its  zenith  in  incidence  and  mortality, 
cinchona  was  scarce  and  expensive;  in  the  period  of  decline,  importation  had 
fallen  off,  cinchona  preparations  were  abundant  and  cheap,  and  conditions 
favorable  to  extensive  mosquito  breeding  were  gradually  reduced  to  a  com¬ 
paratively  low  point. 

In  this  connection,  there  remains  to  be  considered  yet  another  factor,  namely, 
the  possible  inability  of  the  malignant  types  of  malarial  parasites  to  preserve 
their  lethal  force  for  an  indefinite  period  in  an  uncongenial  climate.  Experi¬ 
ence  has  demonstrated  that  the  victims  of  severe  chronic  malaria  acquired  in 
tropical  or  subtropical  countries,  and  which  has  resisted  specific  treatment, 
often  improve  and  gradually  recover  after  prolonged  residence  in  cooler  cli¬ 
mates.  It  is  conceivable  that  the  action  of  the  latter,  whatever  its  character, 
may  be  exerted  deleteriously  upon  the  parasite  as  well  as  beneficially  upon  the 
host,  as  is  commonly  believed.  Therefore  it  is  not  improbable  that  virulent 
types  of  malarial  parasites  imported  from  the  West  Indies,  South  and  Central 
America,  and  the  South  Atlantic  and  Gulf  States  became  so  modified  in  the 
bodies  of  their  local  hosts  during  the  relatively  severe  winters  of  Baltimore 
that,  when  transferred  to  new  hosts  with  the  reappearance  of  mosquitoes  in 
successive  summers,  while  preserving  their  infective  qualities,  they  suffered  a 
reduction  in  their  lethal  force.  Such  modifications  may  have  been  either  rapid 
or  gradual.  Modifications  in  virulence  may  have  been  induced,  in  part  at  least, 
by  the  deprivation  in  the  northern  climate  during  several  months  in  the  year 
of  the  accustomed  opportunity  of  the  parasites  constantly  enjoyed  in  hot 
climates,  for  frequent  change  to  new  human  hosts  and  for  possible  reorganiza¬ 
tions  in  the  bodies  of  new  mosquito  hosts  necessary  for  the  preservation  of  their 
virulence  to  man. 

With  typhus  fever,  frequently  imported,  long  endemic,  and  often  occurring 
in  serious  epidemic  outbreaks,  neither  sanitary  measures  nor  specific  treat¬ 
ment  come  into  consideration.  Without  serious  attempt  at  artificial  inter¬ 
ference,  it  died  out  and  afterwards,  when  awakened  again  after  long  slumber 
or  when  reintroduced  from  without,  it  has  invariably  failed  to  spread,  although, 
as  proven  by  the  results  of  inspection  of  school  children,  a  not  inconsiderable 
proportion  of  the  population  was  louse  infested. 

For  the  second  group  of  the  typically  nuisance-borne  diseases,  the  acute 
intestinal  affections,  progress  was  slower.  So  far  as  general  sanitation  is  con¬ 
cerned  this  was  due  not  so  much  to  deficiency  in  knowledge,  but  to  lack  of 
appreciation  on  the  part  of  the  public  of  existing  information  concerning 
the  importance  of  sanitary  measures.  The  situation  was  greatly  complicated 


GENERAL  CONCLUSIONS 


533 


by  the  rapid  growth  of  population,  the  great  cost  of  overcoming  the  consider¬ 
able  physical  difficulties  involved,  and  the  continued  reimportation  on  a  large 
scale  of  all  of  these  diseases,  save  cholera.  This  factor  continues  to  the  present 
day  to  be  of  considerable  importance  in  connection  with  typhoid  fever.  The 
mortality  from  the  group  as  a  whole  was  high  at  the  outset,  and,  running  in  a 
series  of  waves,  reached  a  comparatively  low  point  by  1840.  Then,  after  a 
period  of  heavy  immigration,  associated  with  the  importation  of  cholera, 
typhoid  fever  and  dysentery,  mortality  attained  its  acme  by  1855.  But  for  a 
slight  setback  between  1886  and  1890,  its  decline  has  been  steady  since  1875. 
As  judged  by  mortality,  their  courses  reflect,  on  the  whole,  at  any  given  period 
during  the  109  years  over  which  it  may  be  followed,  the  state  of  general  sanita¬ 
tion  in  regard  to  water  and  milk  supplies,  the  disposal  of  night-soil,  the  extent 
of  fly  breeding,  the  degree  of  importation  of  cases  and  of  infected  foods,  and 
the  efficacy  of  medical  and  nursing  care.  Administrative  control  of  persons  ill 
of  these  diseases  has  played  no  part  in  the  result,,  except  in  the  case  of  cholera 
in  1866  and  of  typhoid  fever  since  1916.  That  the  improvements  since  1890 
in  medical  management  and  nursing  in  typhoid  fever  and  cholera  infantum 
and  in  the  feeding  and  care  of  infants  have  exerted  a  favorable  influence  upon 
mortality  from  these  affections  can  not  be  questioned.  The  continued  mor¬ 
bidity  of  typhoid  fever  among  individuals  in  whom  extra-urban  infection  can 
be  excluded  and  of  cholera  infantum,  and  the  occasional  epidemics  of  dysen¬ 
tery  among  infants,  since  the  revolution  in  connection  with  the  control  of 
water,  milk  and  night-soil,  and  the  notable  decrease  in  flies,  all  effective  since 
1917,  suggest  very  strongly  that  transmission  of  their  causal  agents  from 
person  to  person  is  now  limited  very  largely  to  contact,  either  directly  or 
indirectly,  through  foods  infected  in  households. 

Turning  now  to  the  contactive  diseases  and  considering  first  the  two  groups, 
the  exanthematous  and  the  acute  respiratory  affections,  in  which  the  trans¬ 
mission  of  the  causal  agents  is  apparently  restricted  largely  if  not  completely 
to  personal  contact  with  the  sick  or  with  carriers,  it  will  be  recalled  that  condi¬ 
tions  were  entirely  different.  While  the  former  group  as  a  whole  exhibited 
a  marked  decline  in  mortality  between  1875  and  1915,  and  had  indeed  by  the 
latter  date  become  relatively  unimportant,  in  the  quinquennium  ending  in 
1920  the  mortality  for  the  latter  exceeded  the  levels  of  1812-1820  and 
1826-1830. 

The  course  of  the  diseases  of  the  first  or  exanthematous  group  is  remark¬ 
able  chiefly  in  the  following  respects :  Each  important  member,  i.  e.,  small¬ 
pox,  measles,  scarlatina,  and  influenza,  after  repeated  epidemic  visitations, 
finally  achieved  endemicity  and  caused  considerable  mortality.  Two,  scarlet 
fever  and  measles,  without  artificial  interference  afterwards  fell  to  negligible 
grades  of  mortality.  One,  small-pox,  after  a  long  period  of  endemicity  dis¬ 
appeared  completely,  only  to  reappear  twice  (1872-1873,  1882-1883)  in 
severely  fatal,  and  twice  again  in  milder  epidemics.  This  disease  flourished 
and  declined  under  a  laissez-faire  vaccination  policy;  subsided  after  vigorous 
vaccination  campaigns;  and,  though  frequently  reintroduced,  has  failed  to 
become  a  serious  menace  since  the  adoption,  with  the  use  of  potent  virus,  of  a 
vaccination  policy  of  a  moderate  degree  of  effectiveness  in  regard  to  general 
vaccination  of  children  and  revaccination  of  adults.  The  records  show  that 


534  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

while  epidemic  small-pox  attacked  some  individuals  who  had  good  recent  vacci¬ 
nation  scars  and  a  considerable  number  who  had  been  vaccinated  many  years 
before,  the  former  were  invariably  but  slightly  ill  and  among  the  latter  the 
mortality  was  much  lighter  than  among  the  unvaccinated.  It  appears  also 
that  an  attack  of  small-pox  itself  by  no  means  always  conferred  lasting 
immunity,  for  in  severe  epidemics  varioloid,  though  rarely  fatal,  was  by  no 
means -uncommon.  The  evidence  at  hand  indicates  that  the  decline  in  the 
incidence  and  the  mortality  from  small-pox  was  closely  correlated  with  the 
wider  adoption  of  vaccination  with  improved  virus. 

Though  both  measles  and  scarlet  fever  have  declined  conspicuously  in  mor¬ 
tality  since  1880,  they  have  increased  greatly  in  invasive  capacity  or  attack- 
rate.  In  this  respect  they  are  in  singular  contrast  to  typhus  fever,  which  dis¬ 
appeared  spontaneously  and  has  repeatedly  failed  to  spread  after  reimporta¬ 
tion.  Chicken-pox  has  shown  no  decline  in  morbidity  during  the  20  years  for 
which  records  exist.  Influenza,  after  repeated  epidemic  waves,  finally  became 
endemic,  with  a  fluctuating  but  always  appreciable  mortality-rate  since  1890. 
Since  the  pandemic  of  1918,  endemic  influenza  has  risen  above  the  previous 
levels  in  both  incidence  and  lethal  force.  Members  of  this  group  of  diseases 
have  been  imported  frequently  not  only  as  epidemics,  but  many  of  them  more 
or  less  constantly  while  endemic. 

The  group  of  acute  respiratory  diseases  declined  in  mortality  from  the  high 
level  of  1812-1820  to  a  comparatively  low  point  by  1826-1830,  and  continued 
to  rise  almost  unbrokenly  until  1881-1885.  Thereafter  their  mortality-rate 
fell  steadily  until  1911-1915,  but  in  the  last  quinquennium  there  was  a 
decided  reaction.  The  increase  in  mortality  between  1831  and  1885  was 
shared  by  all  three  members  of  this  group,  but  the  decline  between  1886  and 
1915  was  restricted  to  whooping-cough  and  diphtheria,  while  pneumonia 
remained  relatively  stationary.  The  ascent  in  mortality  after  1915  was  due 
almost  entirely  to  pneumonia.  All  three  diseases  were  endemically  established 
prior  to  1812,  and  their  importation  has  been  unrestricted  from  the  beginning. 

Since  no  measures  of  restriction  have  been  attempted  against  pneumonia, 
and  the  inadequate  efforts  to  interfere  with  whooping-cough  date  from  1916, 
the  courses  of  these  diseases  reflect  their  actual  natural  history  in  this  popula¬ 
tion.  While  diphtheria  had  fallen  decidedly  in  mortality  before  the  introduc¬ 
tion  of  intubation  and  of  antitoxin  in  the  last  decade  of  the  nineteenth 
century,  considerable  credit  must  be  given  these  two  measures  in  connection 
with  the  very  decided  secondary  fall,  which  has  occurred  since  1895.  Not¬ 
withstanding  the  institution  of  restrictive  measures  in  1898  and  their  con¬ 
tinuous  amplification  since  this  date,  morbidity,  on  the  other  hand,  has  not 
followed  the  course  of  mortality,  but  has  gradually  increased  in  recent  years. 

Of  the  remaining  acute  communicable  diseases  which  are  or  seem  to  be¬ 
spread  largely  if  not  entirely  by  contact,  epidemic  meningitis,  erysipelas,  and 
puerperal  septicemia  have  declined  in  incidence  and  mortality  in  recent  years, 
while  poliomyelitis  has  come  into  prominence  for  the  first  time.  Since  no 
administrative  measures  have  been  directed  to  the  control  of  erysipelas  and 
puerperal  infection,  declines  in  incidence  and  mortality  from  these  must  be 
attributed  partly  to  their  natural  history  and  partly  to  the  development  and 
practice  of  antisepsis  since  about  1890.  Restrictive  measures  and  antiserum 


GENERAL  CONCLUSIONS 


535 


treatment  may  have  been  instrumental  in  controlling  epidemic  meningitis 
in  the  slight  revival  of  this  disease  in  1917.  There  is  no  evidence  that  efforts 
at  artificial  control  exerted  any  influence  upon  the  course  of  poliomyelitis  in 
and  since  1916. 

Critical  analysis  of  recorded  data  indicates  that  the  observed  changes  in  the 
death-rate  from  tuberculosis  have  not  been  appreciably  influenced  by  improve¬ 
ments  in  general  sanitation  nor  by  restrictive  and  other  measures  applied  to 
persons  and  their  environment  since  1910.  A  decided  decline  in  the  mortality 
from  tetanus  coincides  with  the  development  and  use  of  antisepsis  and  of 
prophylactic  treatment  with  antitoxin,  and  the  control  of  the  use  of  explosive 
crackers  and  caps  by  children. 

It  is  notable  that  the  diseases  whose  courses  have  been  unaffected  by  artificial 
interferences,  but  which  have  at  the  same  time  shown  the  most  conspicuous 
declines  in  mortality,  are  affections  which  are  distinctly  general  or  systemic 
and  without  specific  local  inflammatory  reactions.  In  this  respect  compare 
measles,  scarlet  fever,  and  typhus  with  whooping-cough  and  pneumonia. 
Among  the  affections  which  have  been  subject  to  artificial  interferences  the 
same  holds  true,  as  is  illustrated  by  comparison  of  malaria  and  yellow  fever 
with  the  intestinal  diseases,  diphtheria,  and  pulmonary  tuberculosis. 

The  record  shows  very  clearly  that,  with  the  exception  of  small-pox,  no 
attempts  were  made  to  control  the  spread  of  any  of  the  contactive  diseases  by 
isolation  of  the  sick  and  their  contacts  until  the  closing  years  of  the  nineteenth 
century,  and  that  before  1910  all  efforts  in  this  direction  were  imperfect  in 
execution.  It  has  been  shown  that  for  most  of  these  diseases  such  practices  at 
best  can  in  the  nature  of  the  case  do  no  more  than  prevent  association  of  the 
sick  and  their  household  contacts  with  the  general  public  for  the  period 
between  diagnosis  and  death  or  recovery,  and  can  rarely  cover  the  periods  of 
incubation  and  the  indeterminate  carrier  stage,  except  for  diphtheria  and  epi¬ 
demic  meningitis.  The  extensive  systems  of  disinfection  of  household  and  insti¬ 
tutions  with  formaldehyde  gas  and  of  sterilization  of  garments  and  bedding  by 
steam  or  their  destruction  by  fire  have  signally  failed  to  exercise  appreciable 
influence  upon  the  spread  of  the  causal  agents  of  a  single  disease.  Long  before 
these  practices  were  put  into  effect  the  mortality  of  each  and  every  one 
of  the  diseases  upon  which  they  were  tried  had  declined  conspicuously,  and 
since  these  activities  were  instituted  the  morbidity  of  most  of  them  has 
increased  decidedly.  Upon  tuberculosis,  against  which,  since  1910,  with  the 
exception  of  diphtheria,  the  greatest  and  most  costly  efforts  have  been  expended, 
no  appreciable  impression  lias  been  made  by  these  specific  measures. 

Hospitalization  of  cases  of  acute  contactive  diseases  has  without  doubt 
resulted  in  many  recoveries,  especially  in  recent  years,  but  on  account  of  the 
relatively  small  scale  upon  which  it  has  been  practiced,  if  for  no  other  reason, 
this  procedure  can  not  have  materially  influenced  morbidity.  In  the  few 
diseases  of  this  class,  such  for  instance  as  diphtheria,  scarlet  fever,  tubercu¬ 
losis,  actinomycosis,  and  anthrax,  whose  causal  agents  may  be  transmitted  by 
the  mediation  of  foods  as  well  as  by  contact  with  infected  human  beings,  and 
for  some  of  them  with  lower  animals,  the  methods  of  restriction  developed 
within  the  last  10  years  against  the  typically  food-borne  diseases  have  doubt¬ 
less  narrowed  this  avenue  of  infection. 


536  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


In  the  period  under  review,  the  scope  and  character  of  the  investigation  of 
school  children  in  practice  can  have  had  no  effect  upon  the  control  of  the  com¬ 
mon  contactive  diseases  in  individuals  of  this  age.  It  is  pertinent  to  remark 
in  this  connection  that  even  the  most  elaborate  system  of  inspection  of  school 
children  with  the  exclusion  of  those  found  ill  could  not  by  any  possibility 
seriously  control  morbidity  from  these  diseases,  for  this  crucial  reason — the 
chief  incidence  of  all  the  important  diseases  of  this  class  is  in  the  age-group 
below  school  age.  It  would  appear,  indeed,  that  the  supposed  correlation  in 
time  between  the  opening  of  schools  and  the  increase  of  the  various  com¬ 
municable  diseases  of  childhood  either  does  not  exist  in  fact  or  is  spurious. 
These  seasonal  variations  of  incidence  were  well  established  before  there  were 
schools  for  the  larger  part  of  the  child  population,  and  for  but  one  of  the 
affections  under  discussion  (diphtheria)  does  the  attack-rate  usually  increase 
significantly  in  the  early  fall.  For  most  of  them  the  acme  is  reached  in  the 
late  winter  or  spring.  That  the  morbidity  from  these  diseases  may  be  reduced 
in  some  comparatively  small  degree  by  a  constant  and  close  inspection  of 
children  in  school,  followed  by  exclusion  of  recognized  cases  may  be  granted, 
but  in  the  cities  where  it  has  been  adopted  there  is  no  evidence  that  over  a  term 
of  years  the  morbidity-rate  has  been  seriously  affected.  Among  other  reasons, 
the  other  sources  of  contact  in  a  large  community  are  sufficiently  great  for  the 
transmission  of  the  causal  agents  of  these  affections.  For  the  occasional  pro¬ 
tection  of  a  few  individuals  the  procedure  is  undeniably  effective,  but  the  point 
here  insisted  upon  is  that  for  the  mass  of  individuals  composing  the  most 
susceptible  portion  of  the  population  it  can  afford  no  really  adequate  and 
permanent  defence.  The  intelligent  use  of  detention  wards  for  candidates 
for  admission  has  seemed  to  prevent  the  entrance  over  long  periods  of  time  of 
certain  of  these  affections  into  closed  institutions  harboring  young  children, 
and  this  procedure  is  reasonable. 

In  regard  to  the  introduction  from  without,  it  has  been  shown  that  until 
very  recent  years  maritime  quarantine  afforded  a  very  ineffectual  barrier.  It 
not  only  failed  to  hold  against  the  particular  diseases  it  was  designed  to 
exclude,  but  overlooked  many  more  which  it  should  have  kept  out.  Nor  have 
other  portals  been  protected.  With  the  exception  of  plague,  every  communi¬ 
cable  disease,  from  yellow  fever  to  leprosy,  prevalent  in  the  United  States, 
has  entered  from  time  to  time  by  Baltimore’s  back  or  side  doors.  Nor  is  it 
possible  to  prevent  this,  and  the  reverse  is  equally  true.  The  important  diseases 
dealt  with  in  this  free  interchange  are  malarial,  yellow,  typhus,  scarlet,  and 
typhoid  fevers,  cholera,  dysentery,  diarrhoea,  small-pox,  chicken-pox,  measles, 
influenza*  diphtheria,  whooping-cough,  pneumonia,  meningitis,  poliomyelitis, 
tuberculosis,  and  the  venereal  diseases. 

The  official  mortality-rates  from  yellow  fever,  typhus  fever,  small-pox,  and 
tuberculosis  have  been  materially  reduced  as  the  result  of  exportation  of  cases 
to  hospitals  situated  without  the  city  limits. 

In  the  period  under  review,  except  for  the  prevention  of  ophthalmia  neona¬ 
torum,  no  attempts  have  been  made  by  the  health  authorities  to  control  the 
prevalence  of  the  so-called  venereal  diseases.  The  Baltimore  population  has 
been  dominated  in  this  respect  by  the  traditional  bonds  imposed  alike  by  the 
fallacies  of  religious  custom  and  moral  prudery,  according  to  which  cure  of  the 


GENERAL  CONCLUSIONS 


537 


transgressor  infected  while  breaking  the  illy-kept  code  of  sexual  morality  is 
permissible  or  even  laudable;  education  in  methods  of  prevention  are  inter¬ 
dicted.  In  an  age  in  "which  the  chief  shibboleths  are  education  and  personal 
hygiene,  for  the  important  diseases  whose  natural  history  best  lends  itself  to 
the  influence  of  protective  measures  personally  applied,  technical  instruction 
in  their  use  is  proscribed,  although  it  is  well  established  that  promiscuous 
intercourse,  upon  which  their  spread  is  so  largely  dependent,  shows  no  signs 
of  actual  decrease. 

It  will  be  profitable  to  inquire  into  the  degree  in  which  improvement  in 
medical  treatment  and  care  may  have  favorably  influenced  the  course  of  mor¬ 
tality  of  the  febrile  diseases  since  the  opening  of  the  nineteenth  century. 
It  is  evident  that  consideration  must  be  given  to  changes  in  methods  of  use  as 
well  as  in  the  number  and  kinds  of  remedial  agencies  available  at  different 
periods. 

Strictly  medical  treatment,  as  opposed  to  mechanical  or  surgical  measures 
fall,  when  reduced  to  simple  terms,  into  two  broad  classes,  the  topical  and  the 
systemic.  The  members  of  the  former  class  act  chiefly  as  protectives,  diluents, 
detergents,  irritants,  corrosives,  astringents,  and  antiseptics,  and  are  applied 
to  the  skin  or  to  the  mucous  membranes  of  the  conjunctival,  nasal,  buccal, 
faucial,  gastro-intestinal,  and  genito-urinary  tracts.  Of  these,  many  efficient 
representatives  have  been  used  from  time  immemorial.  In  the  light  of  mod¬ 
ern  knowledge,  but  little  curative  value  may  be  conceded  to  them  in  the 
exanthematous  diseases,  pneumonia,  whooping-cough,  or  diphtheria.  It  is  con¬ 
ceivable  that  emetics  may  have  influenced  in  occasional  cases  the  separation 
and  expulsion  of  the  false  membranes  of  laryngeal  diphtheria.  In  diarrhoea  and 
dysentery,  and  perhaps  in  cholera,  cathartics,  astringents,  antiseptics,  and 
clysters  have  undeniably  exerted  a  favorable  influence  upon  mortality.  Sim¬ 
ilarly,  in  the  treatment  of  gonorrhoea  and  other  infections  of  the  genito¬ 
urinary  tract,  and  of  various  pyogenic  infections  of  similar  character,  some 
of  them  have  been  efficacious.  That  remedies  of  this  class  have  been  applied, 
except  under  the  influence  of  modern  surgery,  with  more  skill  and  judgment 
in  recent  than  in  earlier  years  may  well  be  questioned. 

The  systemic  remedies,  which,  by  some  means,  usually  absorption  from  body 
surfaces,  reach  the  vascular  streams  and  thus  become  more  or  less  widely  trans¬ 
ported  through  the  organism,  exert  their  influence  upon  certain  organs  and 
systems  directly  and  upon  the  system  as  a  whole  indirectly.  The  medicines  of 
this  class  applicable  to  the  treatment  of  the  febrile  diseases  may  be  divided  for 
present  purposes  into  several  main  classes:  The  stimulants,  such  as  alcohol, 
ether,  camphor,  caffein  (in  coffee),  digitalis,  nux  vomica;  depressants,  such 
as  veratrum  viride,  aconite,  mercury;  narcotics  and  hypnotics,  such  as  opium 
and  its  derivatives,  chloral,  the  bromides,  and  the  like ;  the  diuretics,  such  as 
various  salts  of  potash  and  soda,  squills,  and  digitalis;  diaphoretics,  such  as 
camphor,  etc.;  expectorants,  such  as  various  salts  and  vegetable  extracts; 
tonics,  such  as  iron,  arsenic,  mercury,  cod-liver  oil;  alteratives,  such  as  the 
salts  of  iodine  and  various  vegetable  extracts ;  antispasmodics,  such  as  ether, 
chloroform,  turpentine,  assafoedita;  specifics,  such  as  cinchona  for  malaria, 
mercury  for  syphilis,  ipecac  for  amoebic  dysentery.  These  are  typical  repre¬ 
sentative  drugs  used  internally  in  the  treatment  of  the  febrile  diseases  during 


538  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

most  of  the  nineteenth  century.  Most  of  them  appear  in  the  Formulae  Selectae 
(67)  of  Drs.  Samuel  K.  Jennings  and  Thomas  Owings,  collected  between 
1808  and  1825.  Many  other  agents,  some  falling  under  other  classes,  were 
in  common  use.  Some  were  noxious,  some  perhaps  possessed  healing  virtue, 
and  many  others  were  inert.  With  few  exceptions,  the  coal-tar  derivatives, 
introduced  in  ever-increasing  numbers  since  1875  and  much  lauded  as  febri¬ 
fuges,  can  hardly  be  credited  with  strictly  curative  properties  in  this  class  of 
disease.  Salicylic  acid,  used  first  in  oil  of  gaultheria,  appears  to  exert  a 
specific  curative  effect  in  acute  articular  rheumatism. 

Stimulants  in  the  depression  of  the  acute  stages  of  the  febrile  diseases  and 
tonics  and  alteratives  in  convalescence  doubtless  often  saved  life,  and  the  ease 
from  pain  conferred  by  narcotics  and  hypnotics  must  be  credited  with  salutary 
effects.  It  has  been  pointed  out  already  that  the  exhibition  of  cinchona  on  the 
large  scale  must  have  been  an  important  if  not  the  chief  influence  in  the 
great  reduction  of  morbidity  and  mortality  from  malaria.  It  is  likely  that  the 
routine  use  of  ipecac  in  the  treatment  of  dysentery  was  curative  in  some  cases 
of  the  amoebic  type  of  this  disease.  That  the  curative  powers  of  mercury  in 
syphilis  was,  until  the  introduction  of  salvarsan,  the  sole  artificial  influence 
in  lessening  the  ravages  of  syphilis  can  not  be  denied.  The  favorable  action 
upon  mortality  of  antisera  in  diphtheria,  tetanus,  and  epidemic  meningitis 
fell  in  the  twentieth  and  not  in  the  nineteenth  century.  So  far  as  the  influence 
of  substitution  diseases  is  concerned,  hydrophobia  has  never  been  epidemic 
in  Baltimore,  and  but  small  opportunity  has  been  offered  to  apply  Pasteur’s 
preventative  treatment  for  this  malady.  It  has  been  shown  that  not  until 
after  1882  was  vaccination  routinely  practiced  to  the  degree  necessary  to 
control  small-pox. 

With  the  exception  of  the  beneficent  use  of  the  few  specifics,  it  is  doubtful 
if,  on  the  whole,  so  far  as  drugging  and  blood-letting  in  the  acute  febrile 
diseases  are  concerned,  physicians  did  not  until  recent  years  kill  at  least  as 
many  of  the  desperately  ill  as  they  benefited.  The  poisoning  by  mercury 
pushed  to  salivation  in  diphtheria  and  pneumonia  in  particular  was  certainly 
responsible  for  many  deaths.  There  is  no  evidence  that  any  drugs  or  other 
medicaments  now  or  ever  used  are  capable  of  exerting  specific  curative  effects 
upon  any  of  the  exanthematous  diseases,  nor  upon  typhus  and  typhoid  fevers, 
whooping-cough,  pneumonia,  bacillary  dysentery,  cholera,  the  diarrhoeas 
and  tuberculosis,  nor,  until  the  specific  antisera  came  into  use,  upon  diph¬ 
theria,  epidemic  meningitis,  and  tetanus.  It  may  not  be  denied  that  in  some 
of  these  diseases,  more  particularly  in  those  in  which  the  primary  lesions 
are  seated  in  the  intestines,  the  use  of  topically  applied  cleansing,  astringent, 
and  antiseptic  agents  and  of  stimulants,  narcotics,  and  hypnotics  has  tided 
over  many  individuals  sick  with  these  affections  during  the  critical  period 
while  active  immunity  was  in  process  of  development. 

To  the  improvement  in  the  methods  of  management  of  those  ill  with  febrile 
diseases  for  which  no  specifics  existed,  much  more  credit  for  reduction  in 
case-fatality  is  to  be  given  that  can  be  ascribed  to  the  exhibition  of  drugs. 
The  substitution  of  careful  management  of  those  sick  of  the  febrile  diseases 
for  the  traditional  drastic  bleeding,  drugging,  and  other  depleting  practices 
was  a  great  step  in  advance.  From  small  beginnings  in  earlier  years,  with 


GENERAL.  CONCLUSIONS 


539 


the  growth  of  knowledge  of  pathological  anatomy,  the  “  expectant  ”  or  symp¬ 
tomatic  treatment  emerged  into  prominence  by  1875.  It  was  about  this  time 
that  the  medical  world  rediscovered  and  began  thoughtfully  to  realize  the 
truth  of  the  ancient  doctrine,  vis  medicatrix  natures.  Of  great  service,  indi¬ 
rectly  at  least,  in  the  reaction  against  the  time-honored  practice  of  depletion 
in  acute  febrile  diseases  was  the  school  of  homeopathy.  When  practiced  accord¬ 
ing  to  its  tenets  it  commonly  amounted  to  drugless  treatment,  and  thus,  though 
not  so  realized  by  its  devotees,  it  was  well-nigh  identical  with  that  of  the 
school  of  therapeutic  nihilists  within  the  regular  profession  who  based  their 
practice  upon  the  solid  ground  of  pathological  anatomy  and  controlled  experi¬ 
ment.  In  consequence  of  these  two  movements,  each  resulting  in  the  with¬ 
holding  of  depleting  remedies  and  measures,  the  world  had  the  opportunity 
to  reobserve  the  important  fact  that  in  these  affections  there  is  a  strong 
natural  tendency  to  recovery.  The  revival  of  the  ancient  practice  of  the  free 
use  of  water,  within  and  without,  in  acute  fevers,  of  more  intelligent  feed¬ 
ing,  especially  in  acute  intestinal  disorders  and  in  pneumonia  and  tuberculosis, 
the  improvements  in  nursing  and  in  hospital  facilities,  have  all  had  a  bene¬ 
ficial  influence  in  reducing  mortality.  The  methods  of  the  leading  physicians 
in  1880  or  1890  were  generally  accepted  by  1910.  The  invention,  about  the 
middle  of  the  nineteenth  century,  of  the  hypodermic  syringe,  with  which  reme¬ 
dies  may  be  introduced  rapidly  into  the  system,,  has  had  a  most  important 
influence  in  saving  lives  and  in  hastening  recovery  in  certain  febrile  diseases. 
The  beneficial  effects  of  this  method  of  administering  remedial  agents  were 
gained  first  in  malaria,  syphilis  and  the  diarrhoeal  diseases  (by  accelerating 
the  action  of  the  salts  of  cinchona,  mercury,  and  opium),  and  much  later  this 
instrument  rendered  possible  the  administration  of  the  modern  biological 
remedies  conferring  active  and  passive  immunity,  such  as  the  bacterial  and 
other  vaccines  and  the  various  immune  sera. 

Advances  in  surgery,  or  that  branch  of  the  medical  art  that  seeks  to  give 
relief  by  the  application  of  mechanical  measures,  have  to  a  large  though  not 
accurately  measurable  degree  favorably  influenced  fatality  rates  in  certain 
acute  febrile  diseases.  Its  special  contributions  here  have  been  directed  against 
secondary  suppurative  foci,  such  as  otitis  media,  mastoiditis,  empyaema,  intesti¬ 
nal  perforation,  appendicitis;  puerperal  and  gonorrhoeal  infections  of  the 
female  organs  of  generation;  and  other  suppurative  affections  of  various  other 
abdominal  organs;  chronic  infections  of  the  teeth  and  tonsils;  and  in  bone, 
joint,  lymph-gland,  and  serous  membrane  tuberculosis.  To  the  old  operation 
of  tracheotomy  and  its  modern  substitute  intubation  are  to  be  credited  many 
lives  rescued  from  laryngeal  diphtheria.  In  the  relief  of  mechanical  obstruc¬ 
tions,  such  as  concretions  of  the  urinary  bladder,  kidneys,  and  the  biliary 
system,  of  hypertrophies  of  the  prostate,  of  strangulated  hernia,  and  other 
causes  of  intestinal  obstruction,  the  contributions  of  surgery  to  the  prolonga¬ 
tion  of  life  have  been  notable.  Particularly  in  the  past  30  years  has  the 
mortality  from  tumors  been  influenced  by  surgical  means.  In  connection  with 
injuries  of  various  kinds,  surgery  has  rescued  many  lives.  While  the  field  of 
surgery  has  been  enormously  widened  since  the  introduction  of  anesthesia, 
and  particularly  of  antisepsis,  and  the  development  of  knowledge  of  pathologi¬ 
cal  anatomy  (to  which  it  has  made  large  contributions),  a  large  if  not  the 
major  part  of  its  general  principles  are  of  ancient  date. 

35 


540  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

In  essence,  the  foregoing  picture  represents  a  series  of  struggles  between 
the  individuals  of  the  population  on  the  one  hand  and  groups  of  parasitic 
micro-organisms  on  the  other.  Many  individuals  have  been  attacked  repeatedly 
by  different  species  at  separate  times,  by  several  species  at  the  same  time,  and 
by  the  same  species  several  times.  The  severity  of  these  attacks  has  varied 
greatly  with  different  individuals  and  at  different  periods.  In  this  complex 
conflict  the  population,  though  hard  hit  at  times,  has  never  been  seriously 
menaced,  but  the  invading  micro-organisms  have  often  proved  unable  to 
maintain  the  battle  even  after  repeated  importation. 

Considering  first  the  population,  it  will  be  recalled  that  it  has  been  found 
that  its  members  have  differed  in  their  natural  susceptibility,  as  judged  by 
both  morbidity  and  mortality,  and  that  of  the  variables  it  has  been  possible 
to  analyze  in  these  respects  the  most  important  and  constant  in  their  action 
are  associated  with  age,  race,  and  sex. 

Rates  specific  for  age  demonstrate  beyond  a  question  of  doubt  that  both 
morbidity  and  mortality  of  measles,  scarlet  fever,  chicken-pox,  mumps, 
whooping-cough,  diphtheria,  epidemic  meningitis,  and  poliomyelitis  are  and 
have  been,  so  far  as  these  records  go,  largely  if  not  entirely  confined  to  the 
first  decade  of  life.  Indeed  for  most,  though  not  for  all,  of  these  diseases,  the 
heaviest  incidence  and  fatality  lie  between  the  seventh  month  and  the  fifth 
year.  The  relatively  high  natural  immunity  to  attack  and  fatality  that  exists 
against  these  diseases  during  the  first  6  months  of  life  suffers  a  severe  loss 
between  the  seventh  month  and  the  fifth  year,  but  is  then  gradually  recovered, 
so  that  after  the  tenth  or  fifteenth  year  the  balance  is  restored,  and  whatever 
the  degree  of  exposure,  incidence  and  death  are  relatively  rare.  With  measles, 
which  of  this  group  of  diseases  has  the  highest  degree  of  incidence,  a  large 
part  of  the  immunity  possessed  by  the  population  over  the  age  of  10  is  per¬ 
haps  actively  acquired  as  the  result  of  attacks  earlier  in  life.  Tetanus  and 
erysipelas  belong  to  this  group,  and  until  vaccination  was  widely  adopted, 
small-pox  was  doubtless  in  Baltimore  as  elsewhere  peculiarly  a  disease  of 
childhood.  Concerning  malarial,  yellow,  and  typhus  fevers,  there  are  no 
recorded  data  for  estimating  the  influence  of  age  upon  morbidity  and  mor¬ 
tality,  but  from  common  experience  it  is  well  established  that  the  young  are 
particularly  susceptible  to  these  diseases  when  prevalent.  Diarrhoea  and  dysen¬ 
tery,  while  attacking  all  ages,  have  their  heaviest  mortality  in  early  life — 
and  with  diarrhoea  the  bulk  of  the  mortality  occurs  in  the  first  year.  While  no 
data  concerning  the  age  distribution  of  cholera  are  to  be  found  in  the  records, 
it  is  notable  that  in  cholera  years  the  mortality  from  cholera  infantum  was 
particularly  high.  Typhoid  fever  and  influenza  belong  to  the  group  of  infec¬ 
tious  diseases  that  attack  all  ages,  but  the  mortality  of  the  former  is  rather 
heavier  before  than  after  the  fortieth  year  of  age,  and  the  reverse  is  the  case 
with  the  latter. 

Pneumonias,  both  lobar  and  broncho,  are  characterized  by  high  incidence 
and  mortality  in  early  life,  but  for  20  or  30  years  after  age  10  their  rates  are 
low.  After  the  fortieth  year,  however,  they  gain  renewed  strength  and  attain 
their  acme  in  old  age.  Pulmonary  tuberculosis,  with  comparatively  low  rates 
of  morbidity  and  mortality  in  the  first  decade  of  life,  rises  sharply  during  the 
second  and  third  decades;  its  mortality,  after  maintaining  high  levels  from 
the  thirtieth  to  the  seventieth  years,  subsides  in  extreme  old  age.  For  all  of 


GENERAL  CONCLUSIONS 


541 


the  other  forms  of  tuberculosis  taken  together,  the  mortality  is  particularly 
high  in  the  first  year  and  under  age  5  and,  having  its  highest  point  in  the  first 
decade,  runs  on  an  even  but  relatively  low  level  during  the  remainder  of 
life’s  span. 

From  table  140  it  will  be  noted  that,  in  1920,  infectious  processes  were 
responsible  for  58  per  cent  of  the  total  mortality  under  age  40  and  for  only 
22  per  cent  of  the  mortality  above  this  age-period.  It  is  significant  that  for 
pneumonia,  tuberculosis,  influenza,  syphilis,  and  the  pyogenic  infections 
(puerperal  fever  excluded),  mortality  was  higher  after  than  before  age  40, 
and  that  the  reverse  was  true  for  dysentery,  diarrhoea,  typhoid  fever,  acute 
articular  rheumatism,  and,  as  is  to  be  expected,  from  the  infectious  diseases 
peculiar  to  childhood. 

The  influence  of  race  stock,  as  indicated  by  color,  upon  mortality  from 
some  of  the  communicable  diseases  can  be  measured  with  some  exactness. 
According  to  tradition,  the  morbidity  and  mortality  of  the  mosquito-borne 
diseases  was  much  less  among  negroes  than  among  whites,  but  Buckler 
recorded  that  in  1850  typhus  fever,  a  disease  comparatively  new  to  this  race, 
was  more  common  in  the  negro.  The  records  show  that  of  the  acute  intestinal 
diseases,  cholera  (Buckler),  typhoid  fever,  and  diarrhoea  (cholera  infantum) 
have  been  consistently  more  fatal  to  the  negro  than  to  the  white.  In  1850, 
the  mortality  of  epidemic  dysentery,  on  the  other  hand,  was  four  times  greater 
in  whites  than  in  negroes. 

For  the  typically  contactive  diseases  the  comparison  between  the  negro  and 
the  white  reveals  interesting  and  significant  results.  The  mortality  from 
small-pox,  measles  and  influenza  (except  during  the  epidemic  of  1918)  has 
been  considerably  higher  in  negroes.  The  converse  is  the  case  with  scarlet  fever. 
In  1850,  the  mortality  from  this  disease  was  one-third  greater  in  whites  than 
in  negroes,  and  during  the  past  15  years  the  rate  w^as  nearly  three  times 
greater  in  the  white  than  in  the  negro  race.  It  is  notable  that  while  for  both 
measles  and  scarlet  fever  the  morbidity-rates  were  higher  in  whites,  the  case- 
fatality  rates  were  higher  in  negroes;  in  other  words  the  negro,  though  less 
liable  to  attack,  is  more  apt  to  die  when  attacked  than  is  the  white.  For 
whooping-cough  the  recorded  morbidity  has  been  considerably  greater  among 
whites  than  among  negroes,  but  the  disease  was  four  times  more  fatal  for  the 
latter.  This  means  that  in  respect  to  this  disease  the  negro  is  less  susceptible 
to  attack,  but  when  he  does  contract  it  he  is  less  resistant  to  its  lethal  force 
than  the  white.  In  1850,  the  mortality  from  diphtheria  (membranous  croup) 
was  about  equal  in  the  two  races,  but  since  1905,  at  least,  the  mortality  has 
been  twice  as  great  among  whites  as  among  negroes.  In  recent  years  the  mor¬ 
bidity-rates  have  been  consistently  much  higher  in  the  white  race. 

For  both  lobar  and  broncho-pneumonia,  since  1875  at  least,  the  mortality- 
rates  have  been  markedly  higher  in  the  negro,  and  the  same  holds  true  for 
morbidity-rates  in  1921.  Similarly  for  tuberculosis,  both  pulmonary  and 
other  forms,  the  mortality-rates  for  negroes  have  been  consistently  and 
markedly  higher  than  for  whites.  There  was  no  appreciable  difference  in 
mortality  for  the  two  races  from  epidemic  meningitis,  but  both  morbidity-  and 
mortality-rates  from  poliomyelitis  in  negroes  were  double  those  obtaining  in 
whites  in  the  epidemic  year,  1916.  In  1920,  the  mortality  from  tetanus  was 
somewhat  higher  and  that  from  erysipelas  was  somewhat  lower  in  negroes 


542  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


Table  140. — Comparison  of  rates  of  death  per  100,000  living  population  at  all  ages,  0  to  39 
years,  and  J+0  years  and  over,  from  all  causes  and  from  certain  groups  of  causes,  and  the 
ratios  per  cent  of  mortality  from  the  same  in  these  age-groups  for  1920. 


At  all  ages* 

0  to  3D  years. 

40  years  and  over. 

o 

S  a 

«♦-« 

O 

t-i 

•2ft 

O 

2a 

Causes  of  death. 

-M 

£ 

3 

c  2 

4-> 

£ 

3 

«2 

-4-> 

£ 

3 
c  2 

o  o 

S  to 

o 

V  . 

O  <L> 

S  bo 

0) 

<0  . 

O  QJ 

S  b* 

"S 

U  tj 
a»  2 

U  % 

<D 

-4-> 

a 

*  M 
<L>  2 

aj  -C 

a 

,  <1> 

tf 

CL 

CL 

« 

CL  u 

a, 

PC 

CL  u 

CL*" 

All  nausea  . 

1548 

994 

2940 

Group  I. 

Cancer  . 

Cardio-vascular-renal  system  in- 

113 

7.3 

•  •  •  • 

15 

1.5 

•  •  •  • 

359 

12 

•  •  •  • 

eluding  embolism  and  throm¬ 
bosis  . 

471 

30.4 

•  •  •  • 

69 

7.0 

•  •  •  • 

1482 

50 

Cirrhosis  of  the  liver . 

Other  diseases  of  liver  and  bil- 

7' 

•  •  •  • 

•  •  •  • 

1 

•  •  •  • 

•  •  •  • 

24" 

•  •  •  • 

iary  system . . 

8 

•  •  •  • 

•  •  •  • 

3 

•  •  •  • 

•  •  •  • 

19 

•  •  •  • 

Diabetes  . 

Diseases  of  the  stomach  (cancer 

21 

•  •  •  • 

0  0  0  0 

4 

•  •  •  • 

•  •  •  • 

64 

•  •  •  • 

excluded)  . 

7 

•  •  •  • 

•  •  •  • 

5 

•  •  •  • 

•  •  •  • 

13 

•  •  •  • 

Hernia  and  intestinal  obstruction 

15 

6.6 

•  •  •  • 

9 

3.8 

•  •  •  • 

32 

10 

Genito-urinary  system  (Bright’s 

•  •  •  • 

y 

> 

disease  and  tumor  excluded)  . . 
Chronic  diseases  of  the  nervous 

11 

•  •  •  • 

•  •  •  • 

3 

•  •  •  • 

•  •  •  • 

30 

•  •  •  • 

system  . 

16 

•  •  •  • 

7 

•  •  •  • 

38 

Leucaemia  and  anaemia . 

7 

•  •  •  • 

5 

•  •  •  • 

14 

Exophthalmic  goitre  . 

2 

•  •  •  • 

1 

•  •  •  • 

4 

Senility  . 

8 

•  •  •  • 

1 

•  •  •  • 

58  ^ 

•  •  •  •  • 

• 

44.3 

•  •  •  •  • 

• 

12.3 

0  0  0  0  0 

• 

72 

Group  II. 

Pneumonia  (all  forms) . 

190 

12.3 

159 

16.0 

267 

9 

Tuberculosis  (all  forms) . 

151 

9.8 

135 

13.6 

190 

7 

Whooping-cough  . 

8] 

in 

0  ] 

Diphtheria  . 

14 

•  •  •  • 

•  •  •  • 

19 

•  •  •  • 

•  •  •  • 

0 

•  •  •  • 

Measles  . 

7 

•  •  •  • 

•  •  •  • 

9 

•  •  •  • 

•  •  •  • 

0 

•  •  •  • 

Scarlet  fever  . 

2 

6.6 

3 

>- 

10.7 

0 

- 

3 

Influenza  . 

44 

•  •  •  • 

•  •  •  • 

41 

•  •  •  • 

•  •  •  • 

52 

•  •  •  • 

Syphilis  . 

22 

18 

32 

Acute  articular  rheumatism.... 

5. 

•  •  •  • 

.... 

6  J 

•  •  •  • 

•  •  •  • 

5  „ 

•  •  •  • 

Typhoid  fever  . 

5' 

51 

4") 

Dysentery  . ' . 

3 

3 

14.7 

2 

7  9 

>- 

*  *  *  * 

1 

Diarrhoea  (including  cholera  in- 

> 

X 

fantum)  . 

105 

139 

19 

Appendicitis  . 

131 

15f 

8 ' 

Wound  and  all  other  infections 
due  to  pyogenic  bacteria, 

•  •  •  • 

y 

2.0 

>- 

3.0 

>» 

1 

puerperal  fever  excepted... 

17J 

•  •  •  • 

•  •  •  • 

14J 

•  •  •  • 

•  •00 

23  J 

•  •  •  • 

•  •  •  • 

•  •  •  •  • 

• 

•  •  •  • 

37.9 

•  •  •  •  • 

• 

•  •  •  • 

58 

0  0  •  0  0 

0 

•  •  •  • 

22 

Group  III. 

Puerperal  state  . 

Affections  peculiar  to  infancy 

18 

1 

•  •  •  • 

24 

2.4 

•  •  t  • 

8 

0  0  0  0 

•  •  •  • 

including  congenital  malfor¬ 
mations  . 

117 

7.5 

•  •  •  • 

8.5 

162 

16.3 

•  •  •  • 

18.7 

0 

•  000 

•  •  •  • 

Group  IV. 

Violence  . 

88 

5.7 

5.7 

68 

6.8 

6.8 

139 

4.7 

4.7 

Total  . 

95.4 

98.8 

98.7 

GENERAL  CONCLUSIONS 


543 


than  in  whites.  During  the  years  for  which  separate  accounts  have  been  kept, 
specific  rates  for  puerperal  fever  were  much  higher  in  the  negro  than  in  the 
white  race.  Unfortunately,  there  are  no  data  available  for  measuring  the 
relative  susceptibility  to  attack  and  death  from  the  febrile  diseases  of  the 
various  branches  of  the  white  race. 

Sex  has  exerted  a  marked  influence  upon  both  morbidity  and  mortality  of 
the  diseases  under  consideration,  and  for  all  of  them  for  which  suitable  data 
are  available  the  rates  have  been  usually  higher  among  males  than  among 
females.  It  is  especially  worthy  of  note  that  with  the  decline  in  the  mortality 
from  pulmonary  tuberculosis  which  began  after  1880,  in  both  the  white  and 
the  negro  races  the  decline  has  been  much  more  abrupt  among  females  than 
among  males. 

It  is  clear  then  that  these  three  attributes  of  the  population,  age,  race,  and 
sex,  have  affected  profoundly  the  course  of  morbidity  and  mortality  of  the 
febrile  diseases  in  the  109  years  under  review,  and  that  changes  in  the  pro¬ 
portional  distribution  of  the  population  in  these  respects  have  influenced 
their  courses  significantly.  It  is  a  matter  of  great  interest  that  the  negro  has 
proved  to  be  less  susceptible  than  the  white  to  malaria,  yellow  fever,  and 
dysentery,  among  the  nuisance  diseases,  and  to  diphtheria,  scarlet  fever,  and 
whooping-cough  among  the  contactive  diseases,  and  that  during  the  last  70 
years,  in  respect  to  the  last  three  diseases,  his  resistance  has  increased  relatively 
and  in  a  decided  degree.  Among  the  other  diseases  for  which  comparison  may 
be  made  over  a  long  period,  the  advantage  still  lies  with  the  white  race  in 
diarrhoea,  typhoid  fever,  tuberculosis,  pneumonia,  and  measles.  In  addition 
to  these,  the  white  has  exhibited  a  higher  degree  of  resistance  to  small-pox, 
typhus  fever,  cholera,  poliomyelitis,  and  the  pyogenic  infections  in  general. 

In  connection  with  the  influence  of  age  upon  the  mortality  from  the  various 
febrile  diseases,  it  has  been  shown  that  in  the  declines  in  the  crude  rates 
exhibited  by  certain  of  these  affections  over  a  long  series  of  years  considerable 
allowance  must  be  made  for  the  known  changes  in  the  age  distribution  of  the 
population,  in  consequence  of  which  the  ratio  of  individuals  of  susceptible  age 
has  declined  or  has  increased.  In  this  respect  the  rates  from  the  diseases  of 
childhood  have  been  affected  favorably  and  those  from  pneumonia  and  pul¬ 
monary  tuberculosis  unfavorably. 

It  will  be  profitable  at  this  point  to  discuss  briefly  certain  biological  dif¬ 
ferences  which  characterize  the  causal  agents  of  the  febrile  diseases. 

The  micro-organisms  causing  the  febrile  diseases  considered  in  this  work 
belong  to  three  fairly  well-defined  groups,  the  obligate  parasites,  the  faculta¬ 
tive  saprophytes,  and  the  facultative  parasites.  The  members  of  the  first 
group,  composed  of  true  and  constant  parasites  which  are  apparently  incapable 
under  natural  conditions  of  prolonged  existence  and  multiplication,  except 
in  connection  with  and  usually  actually  within  the  bodies  of  living  beings — 
man  or  the  lower  animals — are  exemplified  by  the  causal  agents  of  malarial, 
yellow  and  typhus  fevers,  whooping-cough,  measles,  small-pox,  chicken-pox, 
vacinnia,  influenza,  mumps,  epidemic  meningitis,  poliomyelitis,  tuberculosis, 
syphilis  and  gonorrhoea,  and  lobar  pneumonia.  The  causes  of  diphtheria  and 
of  scarlet  fever,  under  usual  circumstances  typical  members  of  this  group, 
occasionally  find  conditions  favorable  for  living  and  even  for  multiplying 
without  living  bodies  in  milk,  an  animal  product,  and  for  this  reason  are  not 


544  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


obligate  parasites  in  the  strictest  sense.  It  is  more  than  possible  that  other 
members  of  this  group — B.  tuberculosis,  to  mention  one — may  also  under 
conditions  met  with  in  nature  grow  in  milk  or  other  substances  containing 
organic  matter.  The  causal  agents  of  malarial,  yellow,  and  typhus  fevers  are 
peculiar  in  the  fact  that  they  require  certain  definite  insects  as  intermediate 
hosts  and  inoculators.  It  is  not  unlikely  that  some  among  the  other  viruses 
mentioned  above  have  similar  affinities.  As  is  well-known,  hydrophobia, 
trypanosomiasis,  and  relapsing  fever  are  caused  by  obligate  parasites  with 
intermediary  hosts. 

Typical  members  of  the  second  group  are  the  micro-organisms  causing  the 
acute  intestinal  diseases,  cholera,  dysentery,  the  diarrhoeas  and  typhoid  fever, 
all  of  which  seem  to  retain  their  vitality  in  water  and  under  favorable  circum¬ 
stances  to  be  capable  of  multiplying,  at  temperatures  below  that  of  the  human 
body,  in  milk  and  in  various  other  substances  containing  organic  matter. 
However,  their  normal  habitat  appears  to  be  the  human  body,  and  especially 
lesions  of  its  alimentary  tract,  and  they  are  rarely  if  ever  found  in  the  outside 
world  except  under  conditions  indicating  pollution  with  human  excreta. 

The  representative  micro-organisms  of  the  third  group  are  the  pyogenic 
bacteria,  well-nigh  ubiquitous  in  the  outside  world  in  soil,  manure,  night-soil, 
and  the  like,  whence  they  easily  reach  the  exposed  surfaces  of  the  human  body. 
In  order  that  they  may  invade  the  tissues  and  establish  the  condition  of 
infection,  they  commonly,  but  by  no  means  invariably,  require  assistance  in 
the  shape  of  surface  wounds,  destructive  irritants,  or  some  previous  or  con¬ 
comitant  infection.  Such  organisms  as  the  pathogenic  streptococci  and  staphy¬ 
lococci,  B.  tetani,  B.  welchii,  B.  mucosus,  and  B.  pyocyaneus,  are  to  be 
regarded  as  normally  saprophytes.  However,  when  well  established  as  facula- 
tive  parasites,  certain  strains  of  staphylococci  and  streptococci  often,  and 
other  forms  more  rarely,  develop  marked  aggressiveness  and  a  peculiar  toler¬ 
ance  for  human  tissues,  and  are  not  only  readily  transmissible  by  direct  and 
indirect  contact,  but  cause  local  epidemics,  of  which  erysipelas,  puerperal  fever, 
umbilical-cord  and  other  types  of  wound  infection  are  familiar  examples. 
As  secondary  invaders,  particularly  in  diseases  caused  by  the  organisms  of 
the  first  group,  they  are  responsible  for  a  long  series  of  complications,  and 
are  very  effective  determinants  of  mortality.  This  association  is  of  peculiar 
importance  in  connection  with  the  exanthemata,  in  which  the  clinical  course 
may  be  greatly  altered  and  the  rate  of  fatality  is  often  largely  determined  by 
mixed  infection  with  pyogenic  bacteria.  Whooping-cough,  diphtheria,  and 
typhoid  and  typhus  fevers  are  frequently  similarly  influenced.  The  causal 
agents  of  these  affections  not  only  provide,  by  injury  to  certain  surfaces  of  the 
body,  favorable  points  of  attack  for  pyogenic  bacteria,  but,  as  has  been  proven 
in  the  case  of  some  of  them,  may  actually  lower  the  general  resistance  to  these 
secondary  invaders. 

It  is  evident  that,  in  the  usually  accepted  meaning  of  the  terms,  examples 
of  nuisance  and  contactive  modes  of  spread  are  offered  by  members  of  all 
three  of  these  groups,  but  that  the  last  two  groups  furnish  on  the  whole  the 
best  examples  of  the  former  mode  of  dispersion.  Malarial,  yellow,  and  typhus 
fevers,  classified  from  the  standpoint  of  public-health  administration  as  nui¬ 
sance  diseases,  in  view  of  the  fact  that  they  are  directly  inoculable  to  man  by 


GENERAL  CONCLUSIONS 


545 


means  of  a  lower  order  of  living  things,  must  be  regarded  from  the  viewpoint 
of  the  causal  agents  as  very  highly  developed  special  cases  of  contact  infection. 
Indeed,  they  are  the  best  known  examples  of  their  type  of  strictly  contactively 
spread  infections,  for  with  them  it  seems  certain  that  all  other  means  of 
transmission  are  excluded.  It  is  evident  from  practical  observation  that  the 
causal  agents  of  the  intestinal  diseases  can  spread  effectively  from  individual 
to  individual  by  direct  contact  alone,  and  in  practice  this  method  is  often 
apparently  an  important  if  not  the  chief  reliance  of  the  causes  of  bacillary 
dysentery  and  infantile  diarrhoea.  The  indirect  method  of  transmission  to 
new  hosts  by  foods,  in  which  they  can  multiply,  and  by  flies  acting  as  mechani¬ 
cal  carriers,  is  for  them  a  fortunate  circumstance  by  which  their  opportunities 
for  transfer  in  effective  dosage  are  greatly  increased.  It  is  clear  from  what 
has  been  said  that,  generally  speaking,  the  pyogenic  infections  are  to  be 
regarded  as  primarily  nuisance-borne,  and  that  their  causal  agents  are  ubiqui¬ 
tous  in  man’s  environment.  Often  their  action  is  more  marked  in  symbiosis, 
in  which  they  have  complicated  the  fight  by  killing  their  host. 

It  is  to  be  recalled  that  healthy  individuals,  as  well  as  convalescents  and 
the  totally  recovered,  have  been  proved  to  harbor  on  the  body-surfaces  and  to 
be  capable  of  disseminating  certain  members  of  each  of  these  groups.  Familiar 
examples  are  B.  diphtherice ,  meningococcus ,  pneumococcus,  B.  typhosus,  B. 
cholerce,  streptococcus,  staphylococcus,  B.  tetani,  B.  mucosus,  and  B.  welchii. 
Numerous  observations  seem  to  warrant  the  inference  that  similar  conditions 
obtain  with  regard  to  the  unidentified  causal  agents  of  the  exanthematous 
diseases.  Among  the  acute  diseases  caused  by  obligate  parasites  and  by  faculta¬ 
tive  saprophytes,  the  carrier  state,  in  or  on  the  bodies  of  both  individuals  who 
have  recovered  and  of  those  who  have  not  themselves  been  successfully  attacked, 
is,  in  the  light  of  present  knowledge,  to  be  regarded  as  the  last  resort  for  sur¬ 
vival  of  their  causal  agents,  and  whence  new  hosts  may  be  invaded  when 
conditions  become  favorable.  Thus  only  can  revival  of  incidence  after  seasonal 
subsidence  be  adequately  explained.  For  those  of  these  agents  upon  which 
experiment  can  be  tried,  prolonged  exposure,  either  to  direct  sunlight  or  to 
drying,  or  to  low  temperatures,  has  proved  fatal.  The  facts  at  hand  seem  to 
indicate  that  the  possibilities  of  indefinite  preservation  of  these  species  of 
causal  agents  in  the  outside  world  are  minimal. 

For  the  obligate  parasites  certainly,  and  for  the  facultative  saprophytes  prob¬ 
ably,  invasion  of  new  hosts  must  be  regarded  as  necessary  for  a  complete  or 
rounded  life  and  therefore  actual  parasiticism  may  be  said  to  be  a  necessity 
for  the  members  of  the  first  two  groups  and  a  luxury  for  the  third  group. 
In  this  sense  true  parasiticism  implies  as  a  normal  condition  of  existence 
multiplication  within  or  at  the  expense  of  the  tissues  of  a  living  host  rather 
than  on  a  body-surface  at  the  expense  of  excrementitious  matter. 

Analysis  of  the  Baltimore  material  emphasizes  the  paramount  influence  of 
season  upon  the  incidence  of  diseases  caused  by  the  parasitic  micro-organisms, 
and  the  evidence  at  hand  indicates  that  these  seasonal  variations  of  incidence, 
and  consequently  of  mortality,  on  the  whole,  are  concerned  more  intimately 
with  the  natural  history  of  the  parasites  than  with  changes  in  the  relative 
resistance  of  their  hosts.  The  spread  of  the  parasites  of  malaria  and  yellow 
fever  was  naturally  restricted  to  the  mosquito  season,  i.  e.,  to  the  warm  months 


546  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

of  the  year.  Typhus  fever  occurred  at  all  seasons,  but  its  greatest  prevalence 
was  in  winter  and  spring.  The  intestinal  diseases,  spread  chiefly  by  foods, 
especially  water  and  milk,  wrere  most  prevalent  in  the  warm  months,  partly, 
at  least,  because  conditions  of  temperature  are  then  most  favorable  for  the 
survival  and  multiplication  of  their  causal  agents  in  these  media  when  infected, 
and  when  carrier  flies  are  active. 

The  exanthematous  diseases  and  pneumonia  sank  almost  invariably  to  low 
levels  in  warm  weather,  gradually  increased  in  activity  in  the  fall,  and  attained 
their  highest  incidence  in  the  winter  and  spring.  Diphtheria,  also  of  low  inci¬ 
dence  in  summer,  increased  rapidly  in  prevalence  in  the  early  fall,  soon  reached 
a  high  level  as  the  weather  cooled,  and,  usually  attaining  its  acme  in  Decem¬ 
ber  and  January,  gradually  subsided  during  spring.  The  course  of  pneumonia 
was  much  the  same,  except  that  the  fall  rise  was  less  abrupt  and  the  peak  was 
attained  rather  later  in  the  winter.  The  monthly  annual  morbidity  and  mor¬ 
tality  of  pulmonary  tuberculosis  followed  the  seasons  in  a  similar  manner. 
With  whooping-cough,  while  the  recorded  incidence  was  about  equally  divided 
between  warm  and  cold  months,  mortality  was  decidedly  higher  during  the 
former.  The  incidence  and  mortality  of  epidemic  meningitis  was  confined  to 
the  late  winter,  the  spring,  and  the  early  summer.  While  sporadic  cases, 
usually  fatal,  of  poliomyelitis  occurred  in  winter  and  spring,  the  chief  out¬ 
breaks  of  this  disease  have  been  confined  to  late  summer  and  early  fall. 

These  facts  suggest  very  strongly  that  the  causal  agents  of  such  of  these 
diseases  as  are  transmitted  from  person  to  person  chiefly  by  direct  contact, 
such  as  the  exanthemata,  whooping-cough,  diphtheria,  pneumonia,  and  tubercu¬ 
losis,  pass  through  alternating  phases  of  invasive  or  aggressive  capacity  which 
are  in  some  intimate  manner  determined  by  meteorological  phenomena,  and 
that  of  these  temperature  is  the  predominant  factor.  In  this  connection  it  is 
not  necessary  to  assume  the  existence  on  the  part  of  these  organisms  of  com¬ 
plicated  life-cycles  such  as  characterize  certain  protozoa.  Cool  or  cold  weather 
or  some  accompanying  physical  state  or  states  may  act  simply  as  stimulants 
to  drive  them  to  the  cover  of  the  tissues  of  appropriate  hosts.  As  has  already 
been  pointed  out,  adequate  explanation  of  the  influence  of  temperature  in 
general  upon  the  prevalence  of  the  nuisance  diseases  is  found  in  its  determin¬ 
ing  influence  upon  environmental  conditions  which  favor  the  multiplication  or 
the  special  modes  of  spread  of  their  causal  agents.  However,  for  the  intestinal 
diseases,  except  cholera,  whose  cause  can  not  survive  cold,  warm  weather  must 
be  regarded  as  only  an  adjuvant  and  not  a  necessity,  for  large  outbreaks,  in  the 
case  of  sudden  and  massive  pollution  of  drinking-water,  may  occur  in  cold 
weather. 

The  contrary  behavior  of  epidemic  meningitis  and  of  poliomyelitis,  as  com¬ 
pared  with  the  exanthematous  and  the  respiratory  diseases,  makes  necessary 
the  assumption  that  the  aggressiveness  of  their  causal  agents  is  stimulated 
by  factors  associated  with  hot  rather  than  with  cold  weather,  or  that  their 
multiplication  and  their  spread  to  individuals  is  determined  by  some  other 
environmental  factors,  including  perhaps  intermediate  hosts.  It  is  significant 
that  for  the  typical  contactive  diseases  it  is  not  the  degree  of  cold  or  of  heat, 
but  the  change  from  warm  to  less  warm  atmosphere  with  which  rise  in  invasion 
rate  is  associated,  and  the  suspicion  remains  that  after  all  the  result  is  bound 


GENERAL  CONCLUSIONS 


547 


up  with  season  rather  than  with  temperature  changes  that  accompany  the 
seasons.  This  material  furnishes  no  data  concerning  the  seasonal  and  other 
external  relationships  which  may  influence  the  invasive  capacity  of  the  widely 
different  organisms  causing  the  three  great  contactive  venereal  diseases,  gonor¬ 
rhoea,  syphilis,  and  chancroid.  In  regard  to  the  facultative  parasites,  it  is 
significant  that  the  pyogenic  cocci  when  well  established  as  parasites  are  appar¬ 
ently  more  active  in  cold  than  in  warm  weather.  Familiar  examples  of  this 
phenomenon  are  tonsillitis,  broncho-pneumonia,  and  erysipelas. 

In  their  struggle  for  existence  and  the  preservation  of  their  position  in  the 
cosmic  order,  it  is  evident  that  among  other  requirements  for  the  strictly 
parasitic  micro-organisms  causing  the  diseases  under  discussion,  two  are  of 
paramount  importance;  resistance  to  the  protective  powers  of  their  hosts  and 
escape  from  the  lesions  to  the  free  surfaces  of  the  body,  whence  new  hosts  may 
be  invaded.  The  interplay  of  forces  involved  in  the  first  constitutes  an  impor¬ 
tant  part  of  the  large  field  of  immunity,  a  subject  which  can  not  be  considered 
exhaustively  here.  In  regard  to  the  second,  it  will  suffice  to  indicate  that  for 
each  of  the  parasites  of  the  nuisance  and  of  the  contactive  diseases  here  con¬ 
sidered,  this  point  is  in  the  main  well  covered.  To  recall  a  few  examples,  the 
parasites  of  the  insect-borne  diseases  have  developed  the  elaborate  system  of 
intermediary  hosts,  and  for  nearly  all  of  the  rest  ample  opportunity  is  given 
for  escape  to  body-surfaces,  often  by  means  of  superficial  lesions,  as,  for 
instance,  by  the  sputum  in  pneumonia  and  pulmonary  tuberculosis,  the  skin 
or  the  mucosas  for  the  exanthematous  diseases,  the  intestinal  ulcers  of  typhoid 
fever,  the  skin  in  erysipelas.  With  others,  of  which  whooping-cough,  diph¬ 
theria,  cholera,  dysentery,  and  diarrhoea  are  familiar  examples,  the  essential 
lesions  are  superficial  and  exit  to  new  hosts  by  direct  or  indirect  means  is  easy. 
Tuberculosis,  syphilis,  and  gonococcal  and  pyogenic  infections  often  furnish 
examples  of  inclosure  of  the  specific  parasites  in  lesions  of  the  internal  organs 
from  which  escape  is  shut  off,  whether  the  host  lives  or  dies,  as  in  tuberculous 
meningitis,  syphilitic  myocarditis,  gonococcal  and  streptococcal  endocarditis. 

In  considering  the  natural  history  of  the  transmissible  diseases,  it  has 
become  customary  to  view  them  entirely  from  the  standpoint  of  the  host,  and 
to  overlook  the  important  fact  that  it  is  invasive  and  not  lethal  capacity  that, 
biologically  speaking,  suits  the  best  interest  of  their  parasites.  It  is  self- 
evident  that,  among  the  diseases  caused  by  obligatory  parasites  and  facultative 
saprophytes,  death  of  the  host  is  inimical  to  the  propagation  of  the  parasite 
species,  and  that  the  shorter  the  period  between  invasion  and  the  occurrence  of 
death  the  less  the  opportunity  for  development,  multiplication,  and  escape  of 
the  parasites.  From  the  standpoint  of  the  parasite  species  the  death  of  the  host 
is  not  a  triumph,  but  a  calamity.  For  the  satisfactory  development  of  a  strain 
of  tubercle  bacilli,  for  instance,  it  is  much  more  advantageous  that  the  host 
should  survive  for  years,  with  ulcerative  pulmonary  tuberculosis,  than  die  in 
a  few  weeks  of  phthisis  florid  a.  The  causal  agents  of  scarlet  fever  and  measles 
are  much  more  safely  intrenched  at  the  present  time  with  their  high  morbidity 
and  low  mortality  rates  than  was  the  case  either  before  these  diseases  became 
endemically  established  or  in  later  years,  when  the  mortality  was  excessively 
high  and  the  morbidity  relatively  low.  Diphtheria  antitoxin,  by  preserving 
the  life  of  those  attacked  and  thus  favoring  the  carrier  state,  has  been  perhaps 


548  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

as  great  a  boon  to  the  diphtheria  bacillus  as  to  the  human  species.  It  is  clear, 
therefore,  that  all  methods  and  means,  whether  they  entail  active  or  passive 
immunity  or  medical  care,  or  even  curative  treatment  with  specifics,  which 
delay  death  or  which  establish  recovery,  if  not  attended  by  destruction  or 
encapsulation  of  the  parasites  in  infected  hosts,  favor  the  propagation  of  the 
invading  organisms  at  the  expense  of  possible  new  hosts. 

It  has  been  pointed  out  in  previous  chapters  that  after  long  endemic  establish¬ 
ment  certain  of  the  acute  parasitic  diseases  which  have  become  characterized 
for  years  by  low  morbidity  and  high  mortality  have  exhibited  marked  gains 
in  invasive  capacity  with  the  loss  of  lethal  force.  Clear-cut  examples  of  this 
phenomenon  are  furnished  by  the  courses  of  measles,  scarlet  fever,  whooping- 
cough,  and  diphtheria.  In  this  case  it  is  evident  that  the  result  may  be  affected 
by  changes  in  the  constitutional  attributes  of  both  the  population  and  the  para¬ 
sites.  Since  in  these  particular  diseases  both  attacks  and  deaths  are  confined 
so  largely  to  early  youth,  the  period  of  life  before  procreation  is  possible,  high 
case-fatality  rates  must  tend  in  time  to  diminish  in  the  population  the  pro¬ 
portion  of  individuals  with  feeble  natural  resistance  to  lethal  issue;  so  that 
by  a  process  of  natural  selection,  towards  the  end  of  the  period  under  review, 
those  diseases  whose  causal  agents  are  obligate  parasites  have  as  their  material 
for  attack  a  population  descended  from  ancestors,  ( a )  who  resisted  attack 
after  exposure,  (5)  who  were  not  exposed  at  all,  or  (c)  who,  though  succumb¬ 
ing  to  attack,  were  able  to  escape  death.  From  the  standpoint  of  the  parasites, 
natural  selection  must  tend  in  the  long  run  to  favor  the  persistence  of  strains 
of  low  as  opposed  to  those  of  high  virulence,  for  the  latter  by  killing  their 
hosts  limit  their  own  opportunities  to  spread,  and  strains  of  lower  lethal  force 
must  have  much  greater  chances  for  propagation  and  transmission  to  suc¬ 
cessions  of  new  hosts. 

Diphtheria  will  serve  as  an  example  to  illustrate  these  points.  The  record 
shows  that  the  mortality  of  this  disease,  from  at  least  as  early  as  1812  to 
about  1860,  ran  at  a  fairly  constant  and  relatively  low  level.  It  is  attested  by 
an  accurate  observer  (56)  that  as  membranous  croup,  the  type  prevalent  during 
this  period  and  characterized  by  a  very  high  case-fatality  rate  (90  per  cent), 
it  did  not  spread  readily  from  the  sick  to  the  well  in  households  and  neighbor¬ 
hoods.  In  other  words,  while  the  case-fatality  rate  was  nearly  100  per  cent, 
both  the  morbidity  and  the  mortality-rates  among  those  of  susceptible  age 
were  comparatively  low.  Suddenly,  in  association  with  a  pandemic,  when  new 
strains  of  the  causal  agent  were  imported,  both  morbidity  and  mortality-rates 
from  the  previously  prevalent  laryngeal  and  the  new  naso-pha,ryngeal  types 
rose  enormously  and  remained  at  high  levels  for  over  25  years.  Thus,  coinci¬ 
dentally  with  the  presence  in  the  population  of  a  large  proportion  of  children 
sprung  in  part  from  parents  who  had  resisted  the  disease,  mortality  declined 
by  1890  to  near  its  previous  level.  With  the  introduction  of  intubation  and 
of  antitoxin  for  both  cure  and  prevention,  the  adoption  of  compulsory  isola¬ 
tion  controlled  elaborately  by  the  culture  test,  morbidity  has  actually  increased 
in  the  face  of  a  remarkable  decline  in  mortality  and  in  case-fatality  rates. 
Without  these  means  and  methods  of  artificial  interference,  similar  but  even 
more  marked  changes  occurred  in  these  rates  for  measles,  scarlet  fever,  and 
whooping-cough.  These  characteristics  are  in  striking  contrast  to  the  behavior 


GENERAL  CONCLUSIONS 


549 


of  certain  other  diseases,  such  as  pneumonia,  typhoid  fever,  and  pulmonary 
tuberculosis,  which  are  not  confined  to  the  lower  age-groups  of  the  population 
and  in  which  the  duration  of  the  illness  is  on  the  whole  rather  longer  and  the 
case-fatality  rate  is  on  the  whole  lower  than  in  the  group  of  affections  just 
discussed. 

However,  such  explanations  of  the  observed  phenomena  can  not  be  con¬ 
sidered  entirely  satisfactory.  It  is  not  improbable  that,  in  consequence  of 
consecutive  passage  through  generations  of  individuals  upon  whom  increased 
resistance  has  been  conferred  by  the  above-discussed  form  of  natural  selection, 
the  causal  agents  of  many  of  these  diseases  have  undergone  actual  as  well  as 
relative  decrease  in  lethal  force.  A  third  alternative  is  the  assumption  that 
among  the  progeny  of  single  organisms  or  of  groups  of  organisms  there  should 
occur  as  a  normal  condition  several  or  even  many  strains  differing  among 
themselves  in  respect  of  invasive  and  lethal  capacities.  In  this  case  the  increase 
or  decrease  in  either  one  or  both  of  these  attributes  occurring  in  connection 
with  a  particular  disease,  when  endemically  established,  may  be  considered  as 
being  due  to  a  chance  or  even  to  a  cyclic  predominance  of  these  respective 
characters  to  an  unusual  degree.  Similarly,  the  subsidence  almost  invariably 
observed  in  respect  of  one  or  both  of  these  qualities  within  a  comparatively 
short  time,  even  when  no  restrictive  interferences  are  interpolated,  may  be 
associated  with  the  return  in  the  mass  of  the  prevalent  strains  to  their  previous 
state. 

Lastly,  it  is  possible  that  increases  and  decreases  in  invasive  and  in  lethal 
force  on  the  part  of  the  obligate  parasites  may  be  due  at  some  times  to  definite 
mutations  in  the  sense  of  DeVries  and  at  other  times  to  the  becoming  domi¬ 
nant  of  characters  long  latent.  Some  such  hypothesis  is  almost  necessary  for 
the  explanation  of  such  sudden  and  great  changes  in  these  respects  as  occur 
in  the  life-history  of  parasites  at  the  time  of  great  pandemics.  Nor  otherwise 
does  it  seem  possible  to  explain  the  repeated  declines  and  complete  disappear¬ 
ance  from  the  city  of  scarlet  fever,  measles,  influenza,  and  typhus  fever,  after 
epidemic  outbreaks  and  in  the  absence  of  any  measures  of  control,  and  of 
small-pox  under  the  same  conditions,  except  imperfect  vaccination.  In  the 
solution  of  these  many  and  complex  phenomena  more  than  one  formula  seems 
necessary. 

One  set  of  parasites  by  determining  the  death  of  hosts  is  often  inimical  to 
another.  While  the  parasites  of  most  of  the  typical  specific  diseases  do  not  as 
a  general  rule  invade  the  same  host  at  the  same  time,  their  hosts  are  often 
attacked  by  facultative  parasites,  particularly  the  streptococci  and  staphylococci, 
and  frequently  with  fatal  results.  Familiar  examples  are  furnished  by  the 
exanthemata,  diphtheria,  whooping-cough,  typhoid  fever,  and  pulmonary 
tuberculosis.  The  coincidence  of  epidemics  of  a  disease  caused  by  an  obligate 
parasite  with  one  caused  by  a  facultative  parasite  may  be  associated  with  the 
augmentation  of  the  lethal  force  of  both.  Illustrative  instances  are  furnished 
in  the  simultaneous  occurrence  of  epidemics  of  scarlet  fever  and  of  erysipelas, 
and  of  influenza  and  of  streptococcus  pneumonia.  Similarly,  the  occurrence 
of  an  epidemic  of  a  disease  caused  by  an  obligatory  parasite  may  increase  the 
case-fatality  rate  of  another  disease  of  the  same  class  or  of  one  due  to  a  faculta¬ 
tive  saprophyte.  Striking  examples  of  this  interaction  are  afforded  by  the 


550  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


influence  of  the  influenza  of  1918  upon  the  case-fatality  rates  of  whooping- 
cough  and  of  typhoid  fever  in  Baltimore.  The  simultaneous  occurrence  in  the 
same  individual  of  two  or  more  diseases  caused  by  obligate  parasites  is,  how¬ 
ever,  not  unknown;  the  subjects  of  the  venereal  diseases  and  of  tuberculosis 
are  apparently  at  least  as  vulnerable  to  other  infections  of  this  class  as  are  the 
healthy,  and  syphilis,  gonorrhoea,  and  chancroid  often  coexist  in  the  same 
person.  While  the  curious  quality  possessed  by  vaccinia  and  variola  of 
almost  completely  immunizing  against  each  other  is  without  parallel  among 
diseases,  it  is  quite  possible  that  antagonisms  similar  in  kind  though  less 
marked  in  degree  may  exist  between  other  febrile  diseases.  In  this  connection 
it  is  of  interest  to  recall  that  the  declines  in  the  mortality  from  pulmonary 
tuberculosis  following  influenza  epidemics  in  Baltimore  and  especially  the  fall 
in  its  recorded  morbidity-rate  since  1918  suggest  very  strongly  that,  contrary  to 
generally  accepted  medical  opinion,  non-fatal  attacks  of  influenza  may  actually 
protect,  to  some  degree  at  least,  against  either  incidence  or  fatality,  or  both, 
on  the  part  of  tuberculosis.  The  significant  and  sustained  recessions  in  mor¬ 
bidity  and  mortality  from  pulmonary  tuberculosis  since  the  influenza  epidemic 
of  1918  may  well  be  causally  associated  with  the  circumstance  that  in  this 
epidemic  the  incidence  of  the  disease  was  unusually  heavy  in  young  adult¬ 
hood  and  in  mid-age,  the  very  age-groups  in  which  the  sharpest  declines  in 
mortality  are  known  to  have  occurred  (graph  25).  To  limit  the  observed 
relation  between  this  influenza  epidemic  and  the  subsequent  decline  in  the 
incidence  and  mortality  of  tuberculosis  to  a  supposed  weeding-out  effect  of 
the  former  upon  tuberculosis  susceptibles  in  the  population  is  unwarranted  by 
actual  conditions;  these  declines  have  been  too  great  and  too  lasting  to  be 
accounted  for  by  this  factor  alone  and  since  1918,  with  continuous  sharp 
recessions  in  the  rates  of  tuberculosis  morbidity  and  mortality,  endemic  influ¬ 
enza  has  remained  on  a  high  level  of  incidence  with  a  comparatively  low  case 
fatality  rate. 

Paradoxical  as  it  may  seem  and  abhorrent  to  current  opinion  as  it  is,  from 
the  standpoint  of  the  parasite  the  ideal  condition  of  existence  is  characterized 
by  ready  infections  of  new  hosts  with  minimal  mortality  among  the  victims. 
And,  evidently  from  the  standpoint  of  the  host  population,  with  those  diseases 
against  whose  parasites  science  and  art  have  no  methods  either  of  extermina¬ 
tion  or  of  control,  with  which,  in  short,  the  symbiosis  defies  artificial  control, 
this  is  the  most  satisfactory  arrangement.  After  a  long  interplay  of  their 
respective  forces,  this  condition  has  been  attained  between  the  Baltimore 
population  and  such  diseases  as  measles,  scarlet  fever,  chicken-pox,  and 
mumps.  Whooping-cough  and  tuberculosis  show  indications  of  the  same 
course.  Diphtheria  has  been  influenced  in  the  same  direction  by  natural  forces 
assisted  by  antitoxin.  It  is  conceivable  that,  other  things  remaining  equal,  by 
natural  methods  in  the  course  of  time  one  or  more  of  these  diseases  may 
gradually  lose  its  identity  and  disappear.  On  the  other  hand,  any  one  of  them 
may,  in  the  future  as  in  the  past,  suddenly  change  its  attributes  in  respect  of 
invasiveness  and  lethality. 

For  man,  preventative  inoculation  of  natural  or  of  attenuated  living  or  of 
killed  viruses  or  of  their  products  has  been  widely  used  for  both  prevention  and 
cure.  For  the  latter  purpose  (with  a  few  exceptions,  in  connection  with  some 
of  the  facultative  parasites,  such  as  staphylococci),  the  practice  has  been 


GENERAL  CONCLUSIONS 


551 


barren  of  results,  and  therefore  exerts  no  influence  upon  spread  of  these 
diseases.  Inoculation  for  prevention,  while  successful  in  some  instances,  has, 
all  things  considered,  proved  to  be  by  no  means  a  perfect  means  of  interference 
with  the  propagation  of  parasites  by  transmission  from  old  to  new  hosts. 
Inoculation  with  natural  small-pox  virus,  by  producing  a  milder  type  of  the 
disease,  was  eminently  successful  in  reducing  the  mortality-rate,  but  as  mor¬ 
bidity  "was  raised  to  the  maximum,  from  the  standpoint  of  the  causal  agent 
conditions  were  well-nigh  ideal.  The  highest  degree  of  perfection  in  restraint 
of  spread  of  a  disease  by  inoculation  of  a  living  virus  is  attained  by  Pasteur's 
method  of  inoculating  against  rabies.  The  secret  here  lies  in  the  production 
after  the  inoculation  of  an  attenuated  living  virus  of  an  active  immunity 
during  the  normal  incubation  period  of  rabies,  i.  e.,  between  infection  and  the 
efflorescence  of  the  disease.  Vaccination  against  small-pox  is  a  case  of  sub¬ 
stitution  of  one  disease,  a  mild  one,  for  another  disease,  which  is  ordinarily 
severe.  Here  the  development  of  small-pox  is  not  always  permanently  pre¬ 
vented  in  an  individual  by  a  single  successful  attack  of  vaccinia  any  more 
than  is  the  case  with  small-pox  itself,  whether  naturally  or  artificially  acquired. 
However,  by  judicious  repetition  of  vaccination  perfect  protection  commonly 
is  attained. 

On  a  much  lower  plane  of  value  in  this  connection  ranks  inoculation  with 
the  causal  agents  of  certain  bacterial  diseases  or  their  poisonous  products, 
the  former  attenuated  or  even  killed  and  the  latter  reduced  in  power  by  physi¬ 
cal  or  chemical  means.  The  best  known  examples  which  have  proven  successful 
in  man  are  tuberculosis,  plague,  cholera,  typhoid  and  para-typhoid  fevers, 
dysentery,  staphylococcus  infection,  and  diphtheria.  In  tuberculosis,  the  first 
of  these  in  chronological  order,  the  method  has  at  least  a  very  restricted  field 
of  usefulness.  In  diphtheria,  the  last  of  these  diseases  for  which  preventive 
inoculation  with  the  poisonous  products  of  its  causal  agent  (toxin  with  anti¬ 
toxin)  has  been  tried,  the  results  are  promising.  For  the  rest,  while  these 
measures  are  often  of  service  for  short  periods  of  time  in  emergencies,  and 
especially  among  readily  controlled  groups  of  individuals,  as  in  armies,  on 
ships,  and  in  institutions,  they  commonly  fail  in  the  long  run  to  displace 
permanently  the  parasites  in  ordinary  populations;  the  protective  immunity 
is  usually  transient  and  of  such  a  nature  that  growth  of  certain  of  these  para¬ 
sites  on  the  body-surfaces  is  not  seriously  interfered  with. 

It  has  been  made  clear  that  curative  sera,  both  antitoxic  and  antimicrobic, 
in  so  far  as  they  may  delay  or  completely  inhibit  a  fatal  issue  without  wholly 
destroying  the  parasites  (and  none  accomplish  this  to  a  greater  degree  than 
occurs  under  natural  conditions),  must,  other  conditions  remaining  equal,  favor 
rather  than  restrict  the  spread  of  the  respective  diseases  from  old  to  new 
hosts.  Finally,  in  regard  to  the  whole  list  of  the  “  febrile  ”  diseases,  it  follows 
as  a  logical  necessity  that  any  other  modes  of  curative  treatment  and  all  modes 
of  natural  recovery  which  are  not  associated  with  the  complete  sterilization 
of  the  causal  agents  in  or  on  the  body,  or  which  do  not  result  in  their  perma¬ 
nent  encapsulation  in  the  infected  tissues,  must  favor  the  propagation  of  the 
parasites  and  their  extension  to  new  hosts.  It  follows  further  that,  except 
where  man  has  been  able  to  invent  methods  that  accomplish  these  ends  or 
that  break  down  all  means  of  communication  through  which  infection  is 
36 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


brought  about,  there  is  no  reasonable  hope  that  diseases  of  this  class  may  be 
curbed,  much  less  eradicated. 

In  Baltimore,  in  one  way  or  another  and  in  halting  fashion,  after  a  struggle 
lasting  123  years,  man  has  been  able  to  stamp  out  some  of  the  nuisance  diseases 
(malaria  and  yellow  fever),  to  materially  interfere  with  the  prevalence  and 
mortality  of  others  (the  acute  intestinal  affections),  and  one  (typhus  fever) 
has  well-nigh  dropped  out  without  his  interference.  Of  the  affections  seem¬ 
ingly  spread  chiefly  by  personal  contact,  one  (small-pox)  is  held  in  check 
temporarily  by  substitution,  the  mortality  of  one  (diphtheria)  has  been 
decidedly  reduced  by  medical  treatment  (intubation  and  antitoxin),  one 
(syphilis)  has  probably  been  lowered  in  both  morbidity  and  mortality  by 
specific  medication,  and  several  (the  pyogenic  infections)  have  been  curbed  in 
both  incidence  and  mortality  to  a  considerable  though  not  measurable  degree 
by  antisepsis.  The  incidence  and  mortality  of  one  member  (tetanus)  of  this 
latter  group  have  been  modified  by  administrative  acts  and  specific  antitoxin. 
It  will  be  observed  that  for  this  group  of  contactive  diseases  practically  all 
of  the  changes  in  incidence  and  in  mortality  were  brought  about  by  measures 
that  are  typically  medical  and  applied  for  the  most  part  at  least  by  private 
physicians  in  the  routine  care  of  their  patients.  Even  vaccination,  though 
for  many  years  required  by  law,  is  and  has  been,  except  in  a  few  notable 
instances,  carried  out  mainly  by  private  physicians.  For  the  rest  of  the  impor¬ 
tant  diseases  of  this  class,  including  pulmonary  tuberculosis,  pneumonia, 
measles,  scarlet  fever,  influenza,  whooping-cough,  epidemic  meningitis,  and 
poliomyelitis,  the  struggle  continues  to  be  one  in  natural  selection  between  the 
causal  agents  and  the  host  population,  and  barely,  if  at  all,  modified  by  certain 
medical  or  administrative  interferences. 

Such  gains  over  the  nuisance  diseases  as  have  been  attained  through  admin¬ 
istrative  measures  were  either  complete  or  well  on  their  way  under  the  influ¬ 
ence  of  theories  long  exploded.  The  sequel  has  proved  that  the  early  Balti¬ 
moreans  were  wise  in  confining  their  attention  to  the  nuisance  diseases  and  to 
small-pox,  but  unwise  in  not  dealing  more  expeditiously  and  thoroughly  than 
they  did  with  the  conditions  which  favor  their  spread. 

AFFECTIONS  PECULIAR  TO  CHILD-BIRTH  AND  TO  EARLY  INFANCY. 

The  evidence  at  hand  indicates  that  the  maternal  death-rate  from  causes 
connected  with  child-birth  has  always  been  high  in  Baltimore.  The  course  of 
the  crude  rates  for  this  group  of  causes  suggests  that  the  wide  fluctuations  in 
the  rates  which  occurred  at  certain  periods  of  the  nineteenth  century  were 
due  in  the  main,  at  least,  to  exacerbations  and  recessions  in  the  death-rate 
from  puerperal  fever.  It  would  appear  that  until  after  1900  the  rate  from 
all  other  causes  in  the  puerperal  state  ran  a  fairly  constant  course  on  a  very 
high  level.  Since  1900  the  mortality  from  puerperal  fever  has  declined  consid¬ 
erably,  and  there  has  been  some  fall  in  the  rates  from  other  causes.  During 
the  6-year  period  1915-1920,  the  maternal  child-bed  death-rate  has  averaged 
about  65  per  10,000  births,  and  something  like  30  per  cent  of  this  was  due  to 
puerperal  fever.  The  risk  rate  of  death  from  causes  connected  with  child¬ 
birth  were  nearly  twice  as  great  in  the  negress  as  in  the  white  woman,  and 
from  puerperal  fever  the  mortality  in  the  former  is  more  than  double.  In 


GENERAL  CONCLUSIONS 


553 


spite  of  the  fact  that  for  25  years  a  large  proportion  of  the  deliveries  have 
occurred  under  the  auspices  of  well-conducted  obstetrical  clinics,  the  maternal 
death-rate  from  causes  connected  with  child-birth  continues  to  be  notoriously 
high.  It  appears  that  this  state  of  affairs  is  only  in  part  due  to  the  obstetrical 
activities  of  untrained  midwives. 

The  group  of  affections  responsible  for  such  high  mortality  in  early  infancy 
demands  consideration  here.  Owing  to  lack  of  specific  knowledge,  these  affec¬ 
tions  can  not  be  delimited  with  sharpness  into  the  organic  or  constitutional 
and  the  infectious,  and  the  determination  in  respect  of  the  primary  cause  of 
death  as  between  these  two  categories  of  causes  is  even  more  difficult  than  in 
old  age.  Pathological  anatomists  as  well  as  clinicians  are  impressed  with  the 
difficulty  in  determining  the  actual  cause  of  death  in  a  large  proportion  of 
infants  coming  to  autopsy.  Even  with  those  gross  malformations  evidently 
incompatible  with  independent  life,  it  is  not  ascertained  what,  if  any,  causal 
role  is  played  by  infection.  To  what  degree  deaths  of  seemingly  well  con¬ 
structed  and  developed  infants  are  due  to  underdevelopment,  or  hypoplasia, 
of  important  organs  of  assimilation,  metabolism  and  regulation,  and  in  what 
manner  such  hypothetical  deficiencies  are  caused  by  inter-uterine  infection,  are 
questions  which  are  shrouded  in  mystery.  That  congenital  infections,  especially 
syphilis,  are  common  antecedents  and  concomitants  of  still-birth  and  of 
death  within  a  few  days  after  birth  of  apparently  well-developed  infants  is 
well  established.  Williams  attributed  to  congenital  syphilis  one-fourth  of  the 
deaths  among  a  large  series  of  such  cases  in  his  service  at  the  J ohns  Hopkins 
Hospital. 

The  high  percentage  of  still-births  to  total  births  (6  among  whites  and  13 
among  negroes),  in  1919  and  1920,  indicates  that  the  causes  of  fetal  mor¬ 
tality,  whether  concerned  with  infections,  with  constitutional  defects,  or  with 
poor  obstetrical  care,  continue  to  act  with  unusual  force.  That  post-natal 
infections  are  responsible  in  part  for  the  high  mortality  among  the  newly- 
born  is  attested  by  the  high  death-rate  from  tetanus  neonatorum  that  obtained 
only  recently  in  Baltimore.  It  is  not  unlikely  that  many  deaths  of  young 
infants  are  still  due  to  general  infections  with  pyogenic  bacteria  following 
improper  care  of  the  umbilical  cord. 

It  has  been  shown  that,  as  measured  by  crude  rates  and  by  rates  based 
upon  the  enumerated  populations  under  1  year  of  age  for  the  census  years, 
the  mortality  from  affections  of  early  infancy  (Chapter  XVIII)  was  not 
only  extraordinarily  high,  but  ran  on  a  fairly  constant  level  from  1830  to 
1900,  and  after  the  latter  date  underwent  a  sharp  decline.  The  rates  specific 
for  age  fell  from  11,029  in  1900  to  5,871  in  1920.  Bates  calculated  upon  the 
number  of  reported  live-births  declined  from  5,207  in  1915  to  4,578  in  1920. 
In  the  latter  year  the  mortality  from  this  group  of  affections  comprised  43 
per  cent  of  the  total  mortality  in  the  first  year,  and  84  per  cent  of  this  fell 
within  the  first  month  of  life.  The  mortality  rates  per  100,000  for  the  respec¬ 
tive  rubrics  of  this  group  of  causes,  in  white  and  in  negro  infants  in  1920, 
calculated  on  the  basis  of  the  reported  births,  are  given  in  table  141. 

The  rates  for  negroes  was  conspicuously  higher  in  each  rubric,  but  in  only 
one — congenital  debility — was  the  rate  significantly  greater  in  proportion  to 
the  whole.  Congenital  malformations  were  responsible  for  a  higher  propor- 


554  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

tion  of  the  total  mortality  in  whites  than  in  negroes.  For  the  two  remaining 
rubrics  the  proportional  distribution  of  mortality  was  the  same  in  two  races. 
It  is  significant  that  from  not  only  causes  acting  in  utero  and  at  birth  (still¬ 
births),  but  from  those  operative  most  conspicuously  during  the  first  month 
of  extra-uterine  life,  the  negro  is  a  much  poorer  risk  than  the  white.  That 
this  is  due  largely  to  causes  inherent  in  race  stock  is  supported  by  the  fact 
that  in  a  very  much  larger  proportion  of  instances  than  the  white  the  negro 
infant  has  the  advantage  of  care  before,  during,  and  immediately  after  birth, 
by  the  two  university  obstetric  clinics. 

While  congenital  syphilis,  gonorrhoea,  tetanus,  and  erysipelas  were  credited 
with  rates  of  138,  11,  21,  and  43,  respectively,  or  about  15  per  cent  of  the 
total  mortality  during  the  first  year  of  life,  only  40  per  cent  of  the  mortality 
from  these  four  diseases  was  recorded  as  falling  within  the  first  month  of  life, 


Table  141. 


White. 

Negro. 

Rate. 

P.  c.  of 
mortality. 

Rate. 

P.  c.  of 
mortality. 

Congenital  malformations  . 

929 

22 

1156 

19 

Congenital  debility,  etc . 

2473 

58 

4066 

63 

Other  diseases  peculiar  to  infants.... 

765 

18 

1185 

18 

Convulsions  of  infants . 

63 

1.5 

105 

1.6 

Total  . 

4237 

99.5 

6518 

99.6 

where  the  bulk  of  their  influence  would  be  expected  to  be  felt.  The  inference 
is  clear  that  many  deaths  from  congenital  syphilis  and  from  pyogenic  infec¬ 
tions  occurring  at  and  immediately  after  birth  must  be  hidden  under  the 
rubrics  for  congenital  debility  and  “  other  diseases  peculiar  to  infants.”  In 
the  first  month  of  life  the  proportional  distribution  of  the  mortality  from 
the  other  groups  of  diseases  responsible  for  deaths  in  the  first  year  as  expressed 
in  percentages  of  the  whole,  were:  for  diarrhoea  6,  acute  diseases  of  the 
respiratory  system  8,  and  measles  8.  Scarlet  fever,  influenza,  and  meningitis 
caused  no  deaths  in  this  age-period. 

The  evidence  at  hand  indicates  that  the  gradual  but  very  considerable 
decline  in  the  rate  of  mortality  from  affections  of  early  infancy  which  has 
occurred  since  the  opening  of  the  twentieth  century  has  been  associated  with 
a  number  of  factors.  Among  the  most  important  of  these  are  the  proportional 
increase  in  the  community  of  mothers  of  race  stocks  among  whom  breast¬ 
feeding  of  infants  is  customary,  the  expansion  of  the  activities  of  obstetric 
and  pediatric  clinics,  and  the  development  of  welfare  clinics  for  the  super¬ 
vision  of  the  care  and  feeding  of  infants. 

VIOLENCE. 

Both  of  the  two  classes  of  violence,  the  intentional  (suicide  and  homicides) 
and  the  unintentional  (accidental)  have  been  conspicuous  causes  of  death 
in  Baltimore  for  over  100  years.  While  the  rates  for  all  forms  of  violence  have 
fluctuated  within  considerable  limits  during  this  time,  on  the  whole  there  was 


GENERAL  CONCLUSIONS 


555 


a  decrease  of  5.5  per  cent.  The  mortality  from  intentional  violence  increased 
by  100  per  cent  between  1812  and  1920,  and  that  from  accidental  causes 
decreased  by  20  per  cent.  Drowning,  the  major  cause  of  accidental  death  in 
the  early  history  of  the  city,  declined  in  importance  in  this  respect  by  1850. 
Since  1880,  largely  on  account  of  the  increase  in  steam  and  electric  railroads 
and  in  more  recent  years  of  automobiles,  the  mortality  from  this  cause  of 
death  has  risen  steadily.  Industrial  accidents  are,  in  ordinary  times,  relatively 
unimportant  causes  of  death  in  Baltimore.  As  deaths  from  falls  incident  to 
the  infirmities  of  old  age  are  classified  under  accidents,  the  survival  during 
the  past  50  years  of  a  steadily  increasing  proportion  of  the  population  to  old 
age  has  unfavorably  influenced  the  rate  for  unintentional  violence. 

THE  CHRONIC  ORGANIC  DISEASES. 

In  connection  with  the  chronic  organic  or  degenerative  diseases,  several 
facts  of  far-reaching  importance  stand  out  very  clearly.  The  most  striking 
of  these  facts  disclosed  by  the  various  tables  analyzed  in  previous  chapters 
may  be  summarized  as  follows :  The  mortality  ascribed  to  affections  of  this 
category  is  not  only  confined  very  largely  to  age-period  40  years  and  over,  but, 
as  a  rule,  increases  progressively  and  markedly  in  this  age-group  from  decade 
to  decade  into  old  age.  The  cardio-vascular-renal  system  is  of  all  others  the 
one  most  frequently  the  seat  of  chronic  non-cancerous  degenerative  diseases 
causing  death,  and  in  this  respect  surpasses  all  the  other  organs  of  the  body 
taken  together.  This  is  the  only  organ-system  (or  organ,  the  pancreas  as 
judged  by  diabetes,  excepted)  for  which  mortality-rates  from  affections  of 
this  character,  when  corrected  for  age,  have  advanced  conspicuously  during 
the  last  40  or  50  years.  Cancer  of  the  cardio-vascular-renal  system  is  relatively 
rare.  During  the  last  20  or  30  years  the  mortality  from  cancer  of  the  breast 
and  the  uterus  (and  ovaries)  has  declined  in  association  with  improvement 
in  early  diagnosis  and  in  surgical  measures,  and  when  allowances  are  made 
for  improvement  in  diagnosis  and  in  statistical  classification,  for  deaths  in 
non-residents,  and  for  changes  in  the  age,  sex,  and  race  distributions  of 
the  population,  it  is  doubtful  if  the  mortality  from  cancer  has  increased 
significantly. 

Since  age  exerts  the  controlling  influence  upon  the  lethal  force  of  cancer 
and  of  the  various  non-cancerous  chronic  organic  diseases,  light  will  be  shed 
upon  the  present  discussion  by  a  comparison  of  the  relative  values  of  different 
causes  of  death  in  age-periods  0  to  39  years  and  40  years  and  over  for  the 
census  year  1920.  In  table  140  the  rates  of  mortality,  for  all  ages  and  specific 
for  those  two  age-periods,  from  all  the  main  causes  of  death  are  arranged  in 
four  fairly  well  defined  groups:  (1)  cancer  of  all  organs  and  the  non- 
cancerous  chronic  degenerative  affections  of  various  organs  and  organ  sys¬ 
tems;  (2)  the  definitely  known  infectious  diseases;  (3)  affections  of  the 
puerperal  and  early  infantile  states;  (4)  violence.  A  few  comparatively  unim¬ 
portant  rubrics,  such  as  asthma,  chronic  bronchitis,  certain  non-cancerous 
diseases  of  bones  and  joints,  alcoholism,  and  certain  general  diseases,  have 
been  omitted.  It  will  be  noted  that  under  the  two  age-groups  compared  nearly 
99  per  cent  of  the  total  mortality  is  accounted  for.  While  this  classification 
is  in  the  nature  of  the  case  by  no  means  accurate,  with  certain  reservations 


556 


PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 


it  will  be  found  to  conform  closely  enough  to  actual  conditions  to  warrant  use 
for  the  present  purpose.  The  main  difficulty  concerns  the  confusion  that 
naturally  arises  in  seeking  to  determine  the  direct  influence  of  infectious  pro¬ 
cesses  upon  the  causation  of  the  affections  of  group  1,  and  the  reciprocal 
influence  the  diseases  of  groups  1  and  2  upon  the  incidence  and  mortality  of 
each  other.  It  is  obvious  that  it  is  not  possible  to  separate  each  and  every  one 
of  the  primary  and  secondary  infectious  processes  from  groups  1,  3,  and  4, 
nor  to  make  exact  allowances  for  the  part  contributed  to  the  mortality  of  the 
affections  under  these  groups  by  those  belonging  to  group  1.  However,  these 
difficulties  may  be  overcome  to  a  considerable  degree. 

First  considering  group  1,  there  is  no  convincing  evidence  that  infection  is 
concerned  in  the  causation  of  cancer  and  other  tumors,  chronic  diseases  of  the 
stomach,  hernia  and  intestinal  obstruction,  prostatic  hypertrophy,  leucaemia 
and  essential  anaemia,  exophthalmic  goiter,  and  senility.  Nor  are  infections 
concerned  primarily  in  the  causation  of  the  vast  majority  of  cases  of  cardio¬ 
vascular-renal  disease,  cirrhosis  of  the  liver  and  diabetes,  and  chronic  diseases 
of  the  nervous  system.  It  is  true  that  in  some  instances  among  the  last-named 
affections,  syphilis  is  known  to  play  a  causal  role.  But  according  to  the  cus¬ 
tom  of  the  statistical  division,  in  the  case  of  deaths  from  diseases  of  this  class, 
such  as  aneurism,  arteriosclerosis,  chronic  myocarditis,  cirrhosis  of  the  liver, 
diabetes,  locomotor  ataxia,  and  general  paralysis,  inquiry  was  made  of  the 
attending  physician,  and  in  those  instances  in  which  syphilis  was  acknowl¬ 
edged  to  be  present  such  deaths  were  classified  under  the  rubric  for  syphilis, 
and  thus  the  error  from  this  source  was  largely  though  not  completely  offset. 
It  is  the  exception  and  not  the  rule  for  clinicians  (personal  communication  of 
Dr.  Llewellys  F.  Barker)  or  for  pathological  anatomists  to  be  able  to  identify 
syphilis  as  the  cause  of  chronic  cardio-vascular -renal  disease,  the  most  promi¬ 
nent  member  of  the  group.  In  the  light  of  recent  knowledge,  it  seems  likely 
that  in  most  cases  in  individuals  over  age  40  diabetes  is  the  result  of  vascular 
lesions — a  type  of  arterio-capillary  disease  of  certain  areas  in  the  pancreas. 
Acute  endo  and  pericarditis  and  rubrics  82,  83,  84,  and  85,  of  which  the  most 
important  is  82  (thrombosis  and  embolism),  all  supposedly  primary,  were 
responsible  for  rates  of  11  and  30,  respectively,  for  age-group  40  years  and 
over.  These  are  easily  balanced  by  the  rubric  senility,  deaths  classified  under 
which  are  due  largely  to  breakdown  of  the  cardio-vascular-renal  system. 
Doubtless  many,  if  not  most,  of  the  deaths  ascribed  to  acute  and  chronic  disease 
of  the  gall  apparatus,  with  or  without  calculi,  are  due  primarily  to  lesions 
associated  with  infections,  and  this  would  account  for  most  of  the  mortality 
credited  to  “  other  diseases  of  the  liver  ”  and  of  the  biliary  system.  Also, 
some  allowances  must  be  made  for  deaths  from  acute  Bright's  disease  and  for 
suppurative  nephritis,  renal  and  vescular  calculi.  The  deductions  necessary 
for  these  categories  are  relatively  insignificant. 

The  question  of  pyogenic  infections  occurring  in  the  victims  of  violence 
and  of  chronic  organic  diseases  is  of  importance.  The  susceptibility  of  indi¬ 
viduals  in  these  conditions  to  pyogenic  infections  is  well  known.  In  some 
instances,  as  in  the  case  of  gunshot  wounds  and  crushing  injuries,  the  relation 
is  evident,  but  with  the  chronic  visceral  lesions,  unless  the  individual  is  bed¬ 
ridden,  it  is  often  difficult  to  decide  whether  a  complicating  acute  infection 
such  as  lobar-pneumonia  is  determined  by  the  primary  disease. 


GENERAL  CONCLUSIONS 


557 


When  the  lethal  stage  of  a  chronic  visceral  disease  is  of  such  character  as 
to  cause  obstruction  to  a  natural  outlet,  as  with  prostatic  hypertrophy,  or  is 
associated  with  ulceration,  as  with  some  tumors,  the  local  suppurative  and 
general  infections  with  pyogenic  micro-organisms  so  common  in  these  states 
are  very  evidently  secondary,  and  no  confusion  arises  in  regard  to  either 
causation  of  the  primary  lesion  or  to  statistical  classification.  Similarly,  the 
proneness  of  individuals  in  the  terminal  stages  of  all  of  the  chronic  visceral 
diseases,  and  especially  of  cardio-vascular-renal  disease,  cirrhosis  of  the  liver, 
diabetes,  chronic  disease  of  the  central  nervous  system,  leucaemia,  and  tumors, 
to  develop  acute  pyogenic  infections,  including  broncho-pneumonia,  is  well 
recognized,  and  the  rules  of  statistical  classification  properly  require  that 
deaths  of  such  individuals  be  assigned  to  these  respective  rubrics  of  the  chronic 
organic  diseases.  For  age-period  40  years  and  over,  group  3  is  of  no  impor¬ 
tance,  and  group  4  (violence)  is  a  slightly  less  effective  cause  of  death  than 
before  age  40.  Some  deaths  classified  as  due  to  violence,  notably  from  falls 
in  the  aged,  are  really  due  to  changes  which  go  with  senesence. 

On  further  analysis  of  table  140,  it  is  observed  that  the  proportional  dis¬ 
tribution  of  mortality  among  the  four  groups  and  their  members  varies  very 
widely  for  the  two  great  age-periods  under  consideration.  The  percentages 
of  total  mortality  for  these  groups  were:  at  all  ages,  44,  38,  8.5,  and  6;  age- 
period  0  to  39  years,  12,  58,  19,  and  7;  and  age-period  40  years  and  over,  72, 
22,  0,  and  5,  respectively.  The  differences  in  the  two  age-periods  between  the 
mortality  from  the  infectious  and  from  the  chronic  degenerative  diseases  are 
very  significant.  After  the  thirty-ninth  year,  the  pyogenic  infections,  pneu¬ 
monia,  tuberculosis,  and  influenza,  are  the  only  infectious  diseases  which  con¬ 
tribute  significantly  to  mortality,  and  of  the  rest  syphilis  is  the  only  one  whose 
mortality-rate  is  not  in  a  comparative  sense  negligible. 

In  respect  of  the  chronic  organic  diseases,  for  which  it  has  been  shown  that 
infection  can  play  no  very  important  primary  etiological  role,  the  most  strik¬ 
ing  fact  is  the  outstanding  prominence  of  the  cardio-vascular-renal  system 
as  the  seat  of  fatal  lesions  in  individuals  over  the  thirty-ninth  year  of  age. 
Next  to  these  stands  cancer,  and  at  the  foot  of  the  list  all  the  remaining 
chronic  organic  diseases  taken  together.  In  order  of  their  relative  importance 
as  contributors  to  the  total  mortality,  as  expressed  in  percentages,  they  stand, 
cardio-vascular-renal  disease,  50 ;  cancer,  12 ;  all  other  chronic  organic  diseases, 
10.  In  other  words,  the  chronic  non-cancerous  degenerative  organic  diseases 
were  responsible  for  something  like  60  per  cent  of  the  total  mortality  in  this 
age-period  in  1920,  and  of  this  moiety  the  overwhelming  proportion  was  due 
to  cardio-vascular-renal  disease. 

Since  the  affections  in  group  1  are  the  only  ones  whose  incidence  and  mor¬ 
tality  are  largely  confined  to  age-period  40  years  and  over,  and  since  the  dura¬ 
tion  of  life  is  restricted,  few  individuals  surviving  to  the  eightieth  year  and 
hardly  any  reaching  the  hundredth  year,  this  means  that,  barring  accidents, 
if  the  infectious  diseases  were  entirely  wiped  out,  the  proportional  importance 
of  the  chronic  degenerative  diseases  would  expand  correspondingly.  While 
medical  and  other  methods  of  interference  with  the  natural  course  of  mor¬ 
tality  may  and  do  act  in  some  degree  at  all  age-periods,  they  can,  of  course, 
only  postpone  the  inevitable,  and  this  is  the  logical  end  of  such  activities. 
Considering  only  those  activities  of  this  character  that  are  brought  to  bear 


558  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

on  age-group  40  years  and  over,  it  is  apparent  from  analyses  previously  made 
that  little  influence  in  this  connection  can  be  expected  from  the  operation  of 
measures  of  public-health  administration.  The  question  resolves  itself  into 
the  influence  of  constitutional  vigor,  heredity,  personal  hygiene,  and  medical 
and  social  activities.  In  respect  of  the  two  former  categories,  this  material 
throws  little  light,  beyond  the  facts  that  on  the  whole  the  death-rate  from  this 
group  of  diseases  is  higher  in  negroes  than  in  whites  and  in  males  (except  in 
the  case  of  cancer  of  the  generative  organs)  than  in  females;  that  the  duration 
of  life  is  longer  in  whites  than  in  negroes;  and  that  during  the  last  60  or  70 
years,  in  association  with  and  probably  largely  on  account  of  the  decline  in 
the  mortality  from  the  nuisance-borne  diseases,  from  the  exanthemata,  from 
tuberculosis,  diphtheria,  and  whooping-cough  among  the  transmissible  diseases, 
and  from  diseases  of  early  infancy,  a  much  larger  proportion  of  the  population 
than  was  formerly  the  case  attains  and  surpasses  age  40. 

The  evidence  at  hand  indicates,  however,  that  when  this  type  of  natural 
selection — the  weeding-out  by  these  diseases  in  early  life  of  a  large  propor¬ 
tion  of  the  weak — was  most  effective,  the  members  of  the  population  who 
attained  midlife  were  more  vigorous  of  constitution.  It  has  been  shown  that 
the  mortality  over  the  thirty-ninth  year  has  risen  rather  than  fallen  during 
the  last  50  years;  and  from  a  comparative  study  of  death-rates  specific  for  age 
for  the  various  census  years  from  1830  to  1920,  inclusive  (table  136,  graph 
38),  it  appears  that  a  reciprocal  relationship  obtained  between  the  force  of 
mortality  in  early  and  in  late  life.  That  is,  in  those  periods  of  the  city’s  his¬ 
tory  when  the  toll  of  mortality  was  particularly  heavy  during  the  first  4  or  5 
decades  of  life,  its  rate  was  commonly  relatively  low  in  later  life,  and  con¬ 
versely,  when  for  the  reasons  above  mentioned,  mortality  became  compara¬ 
tively  low  in  early  life,  the  death-rate  in  the  upper  age-groups  ascended  to 
higher  levels.  The  first  condition  was  typical  of  the  earlier  decennia  of  the 
nineteenth  century  and  the  second  characterized  the  last  few  decennia  of  that 
century  and  the  first  two  of  the  twentieth.  In  the  early  period  those  few 
who  survived  the  snares  and  pitfalls  of  early  life  were  relatively  tough  and 
better  withstood  the  vicissitudes  of  midlife  and  old  age.  This  phenomenon  is 
in  agreement  with  the  findings  of  Pearson  (68),  of  Macdonald  (69),  and  of 
Pearl  (70)  in  comparative  studies  of  life-tables  of  ancient  and  modern  popula¬ 
tions,  although,  as  is  to  be  expected,  in  view  of  the  shorter  interval  of  time 
involved  in  the  present  instance,  these  differences  are  less  marked  than  in  the 
case  of  the  comparisons  of  the  duration  of  life  in  the  respective  populations 
studied  by  these  authors.  It  is  evident,  therefore,  that  during  the  last  50  years, 
in  consequence  of  decline  in  the  forces  of  mortality  in  early  life,  a  gradually 
increasing  ratio  of  the  population  has  attained  midlife,  and  that  on  the  whole 
these  individuals  have  proved  to  be  poorer  risks  and  less  capable  of  survival 
to  old  age  than  were  the  proportionally  smaller  numbers  who  reached  age  40 
when  natural  selection  was  more  searching  in  its  action. 

To  what  degree  personal  hygiene  and  changed  conditions  of  living  have 
affected  the  incidence  and  mortality  of  the  diseases  of  this  group  it  is  impossi¬ 
ble  to  reckon.  On  the  whole,  no  large  groups  of  people  have  ever  lived  in  such 
conditions  of  comfort,  protection  from  the  cold,  and  had  food  and  clothing  in 
such  abundance,  variety,  and  quality  as  the  inhabitants  of  modern  American 


GENERAL  CONCLUSIONS 


559 


cities  during  the  last  40  or  50  years;  and  in  Baltimore  conditions  of  this 
kind  have  been  particularly  favorable. 

In  respect  of  the  influence  of  medical  activities,  it  is  evident  that  modern 
surgery  has  resulted  in  the  prolongation  of  the  lives  of  many  individuals  who 
would  otherwise  have  died  of  cancer  and  other  tumors,  of  diseases  of  the  biliary 
and  urinary  passages,  of  prostatic  hypertrophy,  of  ulcers  of  the  stomach  and 
duodenum,  of  hernia  and  of  intestinal  obstruction,  of  acute  infections,  and  of 
various  accidents.  In  the  same  manner,  whatever  improvements  in  medical 
care  and  treatment  that  have  taken  place  have  acted  in  similar  fashion  in 
disturbing  the  proportional  distribution  of  mortality  among  the  various 
members  of  this  group.  It  is  evident,  therefore,  that  any  and  all  causes  which 
have  been  effective  in  prolonging  life  into  mid-age  have  increased  the  chances 
of  death  from  the  chronic  degenerative  diseases. 

Since  in  comparison  with  those  of  the  cardio-vascular-renal  system  chronic 
degenerative  diseases  of  all  other  organs  are  of  minor  importance,  disease 
of  that  system  must  be  regarded  as  the  normal  gateway  from  life  to  death  in 
old  age.  During  the  past  50  years  they  have  grown  decidedly  in  importance 
as  the  cause  of  natural  death.  The  other  members  of  this  group,  cancer  and 
other  tumors  included,  have  apparently  not  gained  in  mortality,  but  owing 
partly  to  natural  causes  and  partly  to  artificial  interference,  have  become 
relatively  of  less  importance  in  this  respect. 

At  this  point  a  very  pertinent  question  arises.  Why  is  it  that  the  large  and 
small  organs  (the  kidneys  excepted)  of  both  internal  and  external  secretion 
and  the  ducts  of  some  of  them,  together  with  the  skin,  the  brain,  the  locomotor 
apparatus,  and  the  sex  organs,  are,  in  comparison  with  the  cardio-vascular- 
renal  so  rarely  the  seat  of  chronic  degenerative  processes  incompatible  with 
continued  life?  A  partial  explanation  lies  in  the  fact  that  the  former  are 
more  commonly  the  seat  of  benign  and  malignant  tumors  which,  in  the  classi¬ 
fication  of  mortality  arbitrarily  adopted  here,  are  withdrawn  from  both 
categories.  This  circumstance  confers  an  artificial  advantage  upon  the  cardio- 
vascular-renal  system.  However,  when  full  allowance  is  made  for  this,  the 
proportional  distribution  of  mortality  is  still  heavily  against  the  latter  system. 
Omitting  from  consideration  for  the  moment  the  influence  of  sex,  in  propor¬ 
tion  to  their  liability  to  give  origin  to  fatal  cancer  after  age  40,  the  organs, 
of  the  body,  arranged  according  to  the  embryological  derivation  of  their  most 
highly  differentiated  or  characteristic  cells,  rank  in  the  following  order  of 
frequency:  endoderm,  ectoderm,  mesoderm.  The  cardio-vascular-renal  sys¬ 
tem  shares  with  other  structures  of  mesodermal  origin  in  a  relative  immunity 
to  cancer.  It  is  from  the  cells  of  endodermic  origin  in  the  highly  differentiated 
glandular  organs  that  cancer  most  frequently  springs.  Next  in  frequency 
stand  cancers  arising  from  the  skin  and  other  organs  whose  most  character¬ 
istic  cells  are  of  ectodermal  origin.  The  relatively  higher  mortality  from 
benign  and  malignant  tumors  in  the  female  is  due  very  largely  to  a  peculiar 
liability  of  this  sex  to  such  growths  of  two  organs  of  mesodermal  origin,  i.  e., 
the  uterus  and  ovaries,  and  of  the  ectodermal  tissues  of  the  cervic  uteri  and 
of  the  breast.  The  higher  mortality  of  the  female  from  cancer  of  the  latter 
organ  is  to  a  considerable  degree  offset  by  the  greater  proneness  of  the  male 
to  develop  cancer  from  the  other  ectodermic  structures,  such  as  the  skin,  the 
lips,  and  the  buccal  mucosa. 


560  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

For  the  rest,  the  comparatively  greater  vulnerability  of  the  cardio-vascular- 
renal  system  in  those  who  survive  the  fortieth  year  must  depend  upon  attributes 
associated  with  structure,  function,  and  extent  of  surface.  Considering  these 
factors  in  inverse  order,  it  is  apparent  that,  taking  into  account  the  heart, 
arteries,  capillaries,  veins,  and  the  parenchyma  of  the  kidneys,  in  surface, 
the  cardio-vascular-renal  system  must  exceed  the  various  visceral  organs 
most  subject  to  chronic  degenerative  lesions  other  than  cancer.  In  bulk,  also, 
the  comparison  is  probably  in  favor  of  the  cardio-vascular-renal  system.  In 
both  design  and  in  function  this  system  has  the  disadvantages  as  well  as  the 
advantages  of  a  highly  coordinated  mechanical  apparatus.  During  life  the 
heart  in  its  capacity  as  a  force  and  suction  pump  never  ceases  in  its  alternate 
phases  of  rhythmical  contraction  and  relaxation,  by  which  it  keeps  in  circula¬ 
tion,  under  considerable  though  varying  pressure  through  the  arteries,  capil¬ 
laries,  and  veins  of  a  double  system,  a  viscid  fluid,  heavily  laden  with  cells. 
The  vascular  portion  of  the  circulatory  system  and  the  kidneys  work  with¬ 
out  cessation. 

The  lining  cells  of  the  heart  and  vessels  and  the  renal  epithelial  cells  are 
delicately  organized  and  highly  differentiated  for  a  variety  of  functions,  and 
are  submitted  to  the  action  of  numerous  and  varied  poisons.  The  valve  seg¬ 
ments  of  the  heart  are  delicately  thin  and  but  poorly  vascularized.  The  rings 
of  the  four  cardiac  orifices  are  but  inadequately  braced  to  withstand  the  great 
pressures  to  which  they  are  often  subjected.  The  muscle-cells  are  highly 
differentiated,  and  the  mechanism  through  which  the  coordination  of  their 
rythmical  contractions  is  controlled  is  delicate  and  one  easily  disarranged  by 
the  stretching  of  the  vascular  rings  and  by  other  lesions.  Through  the  med¬ 
ium  of  the  vagus  nerve  the  rate  of  the  heart-beats  is  subject  to  interferences 
by  stimuli  from  the  central  nervous  system  and  from  conditions  acting  upon 
the  nerve  itself.  The  elastic  tissue  of  the  intima  and  the  fibro-elastic-muscular 
media  of  the  arteries  frequently  give  way  to  constant  and  abnormally  high 
pressures  and  are  susceptible  to  the  action  of  a  number  of  injurious  agents. 
Of  all  the  glandular  organs  of  external  secretion,  the  kidneys  are  the  largest 
and  the  most  highly  differentiated.  Far  removed  from  the  heart,  they  are 
interpolated  on  the  vascular  system  as  excretory  organs,  through  which  passes 
in  a  given  time  a  large  quantity  of  blood  over  an  extensive  and  complicated 
vascular  area.  In  the  kidneys,  as  in  the  case  of  the  heart  and  the  brain,  inter¬ 
communication  among  the  smaller  branches  of  the  main  arterial  branches  is 
not  so  free  as  in  other  important  organs.  In  consequence,  lesions  of  the  arteries 
of  these  important  organs,  such  as  dilatations,  narrowings,  obliterations,  rup¬ 
tures,  and  the  like,  which  are  not  infrequent,  are  fraught  with  more  serious 
results  than  in  other  organs. 

Though  capable  of  considerable  reparation  after  overwork  and  other  injury 
and  of  varieties  and  degrees  of  adaptation  and  compensation  under  mechani¬ 
cal  stresses,  and  in  the  face  of  serious  lesions  that  are  little  short  of  marvelous, 
in  proportion  to  the  burdens  it  is  called  upon  to  bear  the  cardio-vascular-renal 
system  of  the  average  individual  can  not  be  classed  as  designed  to  withstand 
for  an  indefinite  time  the  strain  and  stress  it  is  called  upon  to  bear  in  normal 
life.  Whatever  the  history  in  respect  to  previous  disease  and  abuses,  it  is 
uncommon  to  find  at  autopsy  on  an  individual  of  40  or  50  years  of  age  and 


GENERAL  CONCLUSIONS 


561 


dead  of  any  cause,  even  accident,  perfectly  normal  arteries,  heart,  and  kidneys. 
Above  age  60,  whatever  the  history  of  the  individual  and  the  cause  of  death, 
extensive  changes  in  the  kidneys,  arterial  system,  and  heart  are  to  be  expected ; 
and  in  the  aged,  widespread  and  grave  lesions  of  these  organs  are  nearly 
always  present.  Indeed,  these  changes  are  as  characteristic  of  old  age  as  is 
wrinkling  of  the  skin. 

That  the  changes  of  arterio-sclerosis  are  in  part  due  to  wear  and  tear  in 
keeping  up  the  blood-pressure  throughout  life  is  exemplified  by  the  fact  that, 
whatever  the  age  of  the  individual  or  his  history  of  previous  diseases  and 
excesses,  sclerotic  changes  of  the  type  occurring  in  advanced  arterio-sclerosis 
are  very  rarely  found  in  the  venous  system  in  which  the  blood-pressure  is 
normally  low.  When,  under  very  exceptional  circumstances,  venous  sclerosis 
does  occur,  it  is  commonly  localized  in  some  one  vein  and  evidently  the  result 
of  some  particular  injury.  While  a  number  of  different  degenerative  lesions 
have  been  observed  in  developing  arterio-sclerosis  and  the  reactions  of  repair 
and  compensation  on  the  part  of  the  arteries,  the  kidneys,  and  the  heart  and 
the  mechanism  of  the  circulation  through  all  stages  of  the  process  are  fairly 
well  understood,  pathological  anatomists  are  not  in  agreement  in  the  interpre¬ 
tation  of  the  sequences  and  interrelations  of  the  various  degenerative  and 
reparative  processes  of  the  common  non-syphilitic  arterio-sclerosis. 

In  regard  to  causation,  except  that  the  slowly  developing  senile  type  is  part 
and  parcel  of  senesence,  and  that  there  is  a  relatively  rare  but  quite  character¬ 
istic  syphilitic  type,  accurate  knowledge  is  lacking.  Certain  it  is,  however, 
that  very  occasionally  in  the  relatively  young  and  very  commonly  in  persons, 
both  male  and  female,  between  40  and  55  years  of  age,  a  very  definite  type  of 
illness  begins  with  high  blood-pressure  and  ends  usually  in  a  few  months  or 
years  with  the  clinical  signs  and  anatomical  lesions  of  arterio-sclerosis  and 
nephritis  and  often  of  the  cardiac  valves  and  of  the  myocardium.  In  another 
class  of  cases  disease  begins  as  a  primary  nephritis  and  often  ends  in  death 
with  or  without  extensive  vascular  and  cardiac  lesions.  In  the  typical  senile 
form,  when  not  complicated  with  some  acute  infection,  death  commonly  fol¬ 
lows  apoplexy,  renal  or  cardiac  insufficiency,  or  an  attack  of  angina  pectoris. 
These  and  other  accidents  involving  the  cardio-vascular-renal  apparatus  occur 
in  all  types  of  the  disease.  One  of  the  most  characteristic  concomitants  of 
general  arterio-sclerosis,  especially  in  individuals  between  the  fortieth  and 
sixtieth  years  of  life,  is  the  enormous  cardiac  hypertrophy  which  is  due  to  the 
increased  work  demanded  of  the  heart  to  carry  on  the  circulation  under  the 
new  conditions  of  pressure  which  are  determined  in  part  at  least  by  the 
arterial  changes. 

Finally  to  be  considered  are  the  cases  of  true  endocarditis,  usually  of  the 
valves,  and  which  is  commonly  secondary  to  some  acute  infection.  It  is 
obvious  that  in  fatal  cases  of  cardio-vascular-renal  disease  physicians  ascribe 
death  to  the  lesion  which  is  or  seems  to  be  the  more  prominent  at  the  terminal 
stage,  and  hence  the  variety  of  terms  used  in  medical  nosology  to  cover  these 
protean  lesions.  To  a  great  degree  the  use  of  particular  terms,  such  as  fatty 
heart,  heart  failure,  heart  hypertrophy,  decompensation,  hypertension,  and 
the  like,  are  determined  by  transitory  fashions.  So  it  is  clear  that,  by  design, 
structure,  and  the  nature  of  its  function,  the  cardio-vascular-renal  system 


562  •  PUBLIC  HEALTH  ADMINISTRATION,  ETC.,  IN  BALTIMORE 

is  unsuited  to  stand  indefinitely  the  strains,  stresses,  and  accidents  to  which 
it  is  subjected,  its  very  extent  in  surface  constitutes  a  mass  of  tissue  far 
greater  in  dimension  than  any  other  viscus,  the  character  of  its  lesions  cause 
great  impairment  of  its  functions,  and  the  accidents  to  which  it  is  subject 
are  often  necessarily  fatal. 

Attention  has  been  directed  to  the  fact  that  certain  infectious  diseases, 
notably  pneumonia,  both  lobar  and  broncho,  tuberculosis,  influenza,  and  the 
pyogenic  infections,  display  rising  mortality-rates  after  age  40,  and  it  is 
well  established  that  all  of  these  affections  are  particularly  common  in  the 
terminal  stages  of  the  chronic  visceral  diseases,  and  particularly  of  those  of 
the  cardio-vascular-renal  system.  This  association  does  not,  however,  prove 
that  these  chronic  organic  diseases  per  se  always  determine  incidence  and 
fatality,  for  at  least  two  other  possible  causes  of  lack  in  resistance  with  advanc¬ 
ing  age  must  be  considered — decrease  in  organ  immunity  and  in  the  general 
immunity  provided  by  the  usual  mechanisms,  whatever  they  may  be. 

That  loss  of  organ  immunity  plays  a  large  part  here  is  evident  when  con¬ 
sideration  is  given  to  the  fact  that  the  various  organs  are  affected  in  great 
disproportion,  i.  e.,  the  lungs,  the  skin,  and  the  genito-urinary  system,  espe¬ 
cially  in  the  male,  very  commonly,  while  the  liver,  pancreas,  stomach  and 
intestines,  the  central  nervous  system,  and  above  all  the  cardio-vascular-renal 
system,  in  comparison  preserve  in  very  high  degree  their  normal  organ 
immunity  to  these  processes.  With  advancing  age  the  skin  and  the  pulmonary 
system  return  in  respect  of  weak  resistance  to  attack  and  lethal  force  by  the 
pyogenic  cocci  and  the  causal  agent  of  pneumonia  to  the  status  that  obtains  in 
infancy.  The  asthenic  character  of  the  inflammatory  reactions  to  local  infec¬ 
tions  in  old  age,  and  the  frequency  with  which  the  latter  are  attended  by 
general  bacteriamias,  often  accompanied  by  multiple  foci  of  inflammation, 
indicate  that  in  this  period  of  life  there  occurs  a  deficiency  in  the  various 
defensive  agents  supplied  by  the  body  to  the  blood  and  lymph. 

The  high  correlation  between  the  lethal  force  of  influenza  and  of  cardio- 
vascular-renal  disease  (heart  disease)  pointed  out  by  Bertillon  (64)  and  by 
Pearl  (65)  and  the  high  correlation  between  old  age  and  the  fatality  of  pneu¬ 
monia,  long  recognized,  are  indicative  perhaps  of  the  same  thing,  namely, 
lowered  resistance  due  to  changes  incident  to  advanced  age,  heart  disease  in 
the  correlation  with  influenza  really  standing  for  old  age.  In  the  discussion 
of  influenza  it  was  pointed  out  that  a  large  proportion  of  the  fatal  cases  of  this 
disease  are  complicated  with  pneumonia,  and  that  under  the  rules  those  with 
broncho-puneumonia  are  classified  under  influenza  and  those  with  lobar- 
pneumonia  are  ascribed  to  the  latter  rubric.  Doubtless  many  individuals  in 
the  upper  decades  of  life  who  are  credited  with  dying  of  pulmonary  tubercu¬ 
losis  actually  die  of  cardio-vascular-renal  disease  natural  to  old  age  and  with 
the  lesions  of  chronic  tuberculosis  developed  earlier  in  life,  and  in  itself  con¬ 
sistent  with  continued  life. 

The  sexual  cycle  has  apparently  nothing  to  do  with  longevity  as  determined 
by  chronic  organic  disease  for  woman,  whose  sexual  life-period,  as  tested  by 
capacity  to  reproduce,  is  much  shorter  than  that  of  man,  preserves  after  mid¬ 
life  her  initial  superior  life  expectancy,  and  exhibits  in  old  age  no  higher 
death-rates  than  man  from  the  chronic  organic  diseases  (cancer  of  the  genera¬ 
tive  organs  excepted)  and  a  lower  mortality  from  pneumonia. 


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45.  The  effects  of  the  war  on  the  chief  factors  of  population  change.  Raymond  Pearl, 

Science,  (N.  S.)  51,  1920,  pp.  553-556. 

46.  Statistics  of  mortality  in  Baltimore.  Levin  S.  Joynes,  M.D.,  Amer.  Jour.  Med. 

Sciences,  October,  1850. 

47.  Vital  statistics  of  Baltimore.  Charles  Frick,  M.  D.  Amer.  Jour.  Med.  Sciences, 

October,  1855. 

48.  The  histoiy,  diagnosis,  and  treatment  of  typhoid  and  typhus  fever,  with  an  essay 

on  the  diagnosis  of  bilious  remittent  and  yellow  fever.  Elisha  Bartlett,  M.D., 
Philadelphia,  1842. 

49.  A  treatise  on  epidemic  cholera.  Horatio  G.  Jameson,  M.D.,  Philadelphia,  1852. 

50.  On  the  pathology  of  remittent  fever.  John  A.  Swett,  M.D.,  physician  to  the  New 

York  Hospital.  Amer.  Jour.  Med.  Sciences,  January,  1845. 

51.  Notes  on  cases  of  remittent  fever  which  occurred  at  the  Baltimore  almshouse 

infirmary,  collected  by  W.  F.  Anderson,  M.  D.,  and  Charles  Frick,  M.  D.  With 
an  analysis  of  the  cases  and  remarks,  by  Alfred  Stille,  M.D.  Amer.  Journ. 
Med.  Sciences,  April,  1846. 

52.  A  contribution  to  the  pathology  of  malarial  fever.  Councilman  and  Abbott.  Amer. 

Jour.  Med.  Sciences,  April,  1885. 

53.  Report  of  the  commissioners  of  health  to  the  Mayor  and  City  Council  of  Baltimore, 

consisting  of  facts  and  communications  relative  to  the  health  of  the  city,  since 
their  appointment  and  especially  during  the  prevailing  sickness.  New  York 
Medical  Repositary,  Vol.  I,  November,  1797.  Reprinted  as  3rd  edition  in  1804, 
appendix  pp.  380-391. 

54.  A  bacteriological  and  anatomical  study  of  the  summer  diarrhoeas  of  infants. 

William  D.  Booker,  M.D.  The  Johns  Hopkins  Hospital  Reports,  Vol.  VI,  1897. 

55.  The  etiology  of  summer  diarrhoeas  of  infants.  Duval  and  Basset.  Centralbl.  f. 

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